UTIs UTIs can decrease _____ Hypo-_____ Urea splitting organisms Proteus, Klebsiella, Pseudomonas, Serratia, Staph Urea--\> ammonia + bicarb --\> ____ Proteus --\> _____

ureteral peristalsis citraturia struvite matrix stones

Indications for Acute Intervention Complete or high grade _____ Bilateral _____ Urinary obstruction w/ ______ Urinary obstruction in _____ kidney Urinary obstruction w/ rising ____ Inability to ____ due to severe N/V Severe pain uncontrolled by _____

urinary obstruction urinary obstruction urinary infection solitary creatinine take in POs analgesics

ESWL (extracorporeal shock wave lithotripsy) Done under ____ Done w/ _____ imaging if radio-opaque, ____ if radiolucent, _____ Shock wave generator positioned where? Table manipulated to put stone in ____ Shocks delivered ___-___/ minute Gated w/ ___ to avoid inducing dysrhythmia

sedation/anesthesia fluoroscopic imaging easily seen put up a stent and inject contrast dye against patient's side cross-hairs 60-90 EKG

Which stone? Radiolucent Forms in acidic urine (\<6.0) Dissolves in alkalinized urine

Uric acid (urate) Malingering pts know this stone does not show up on x-ray. But will show up on CT

Prevention of Future Stones Fluid intake, should result in a urine volume of ___ L Encourage fluids w/ _____ , Discourage ____. Low sodium (less urinary Ca, more urinary citrate) Low ___ protein intake (amino acid effect) Low oxalate Moderate Ca intake Avoid high doses of vit __ and ___

2.5 citrate / soda animal C & D

Which stone? Genetic defect, autosomal _____ Heterozygotes usually _____ Homozygotes usually ______ Caused by _____ Dissolved in ____ environment

Cystine recessive hetero --\> NOT stone formers Homo --\> form stones cystinuria alkaline

Tx of upper tract stones (2 locations?) 6 tx options

kidney & ureter Trial of passage Extracorporeal Shock Wave Lithotripsy (ESWL) Dissolution Open or laparoscopic surgery Ureteroscopy w/ stone manipulation Percutaneous Nephrolithotomy (PCNL) (TED UOP)

Tx of Urolithiasis Abx for infection Acute tx to relieve obstruction: _____ ______ (to prevent sepsis / renal damage / loss of renal function) Later proceed to definitive stone management under more controlled circumstances

ureteral stent placement nephrostomy tube placement

Urolithiasis Flashcards by Megan Jacobson

Which stone?

Radio-opaque
Resistant to dissolution
Most commonly caused by dehydration

Calcium oxalate

(MC type in US)

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UTIs

UTIs can decrease _____
Hypo-_____
Urea splitting organisms
- Proteus, Klebsiella, Pseudomonas, Serratia, Staph
- Urea–> ammonia + bicarb –> ____
- Proteus –> _____

ureteral peristalsis
citraturia
struvite
matrix stones

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Which med for Prevention of Future Stones?

Ileal resection –> decreased bile acid absorption
Bile acids increase colonic wall permeability to oxalate –> increase oxalate absorption
___ binds bile acids, decreasing colon wall permeability to oxalate

Cholestyramine

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Indications for Acute Intervention

Complete or high grade _____
Bilateral _____
Urinary obstruction w/ ______
Urinary obstruction in _____ kidney
Urinary obstruction w/ rising ____
Inability to ____ due to severe N/V
Severe pain uncontrolled by _____

urinary obstruction
urinary obstruction
urinary infection
solitary
creatinine
take in POs
analgesics

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3 PE findings of urolithiasis

Fever
Hyperkinetic
CVAT (costovertebral angle tenderness)

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3 “relative contraindications” of ESWL

(extracorporeal shock wave lithotripsy)

cystine stone , matrix stone
chronic pancreatitis / pancreatic calcification
distal obstruction

“COP”

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Dissolution (chemolysis) of Struvite, Calcium phosphate stones

Irrigation w/ _____ (___)

acidic solution (Renacidin)

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3 contraindications of Percutaneous Nephrolithotomy (PCNL)

UTI
Coagulopathy
No percutaneous renal access

(CUN)

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ESWL (extracorporeal shock wave lithotripsy)

Done under ____
Done w/ _____ imaging
- if radio-opaque, ____
- if radiolucent, _____
Shock wave generator positioned where?
Table manipulated to put stone in ____
Shocks delivered ___-___/ minute
Gated w/ ___ to avoid inducing dysrhythmia

sedation/anesthesia
fluoroscopic imaging
- easily seen
- put up a stent and inject contrast dye
against patient’s side
cross-hairs
60-90
EKG

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4 etiologies of metabolic urolithiasis

Hypercalciuria
Hypocitrauria
Hyperoxauria
Hyperuricosuria

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Which stone?

Radiolucent
Forms in acidic urine (<6.0)
Dissolves in alkalinized urine

Uric acid (urate)

Malingering pts know this stone does not show up on x-ray. But will show up on CT

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6 meds to prevent future stones

potassium citrate (raises pH & citrate level)
thiazide
allopurinol
pyridoxine (B6)
Cholesyramine
Thiols

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Which med for Prevention of Future Stones?

decreases uric acid levels
Only decreases stone incidence if pt had been hyperuricosuric*

Allopurinol

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Which med for Prevention of Future Stones?

Corrects acidosis
Increases reabsorption of Ca into kidneys, decreasing urine calcium excretion
Can worsen stone disease, if it causes hypokalemia**
May be given w/ potassium**
2 SE?

Thiazide

weakness & fatigue

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5 contraindications of ESWL (extracorporeal shock wave lithotripsy)

pregnancy
coagulopathy
UTI
Renal Artery Aneurysm
AAA

“U CRAP”

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Prevention of Future Stones

Fluid intake, should result in a urine volume of ___ L
Encourage fluids w/ _____ , Discourage ____.
Low sodium (less urinary Ca, more urinary citrate)
Low ___ protein intake (amino acid effect)
Low oxalate
Moderate Ca intake
Avoid high doses of vit __ and ___

2.5
citrate / soda
animal
C & D

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What is the most common type of stone in the US?

Calcium oxalate

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Which stone?

associated w/ UTI & laxative abuse
Radiolucent

Ammonium Acid Urate

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4 complications of PCNL (percutaneous nephrolithotomy)

bleeding
sepsis
renal pelvis perforation
pneumothorax / hydrothorax

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Which stone?

Genetic defect, autosomal _____
Heterozygotes usually _____
Homozygotes usually ______
Caused by _____
Dissolved in ____ environment

Cystine

recessive
hetero –> NOT stone formers
Homo –> form stones
cystinuria
alkaline

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Tx of upper tract stones (2 locations?)

6 tx options

kidney & ureter

Trial of passage
Extracorporeal Shock Wave Lithotripsy (ESWL)
Dissolution
Open or laparoscopic surgery
Ureteroscopy w/ stone manipulation
Percutaneous Nephrolithotomy (PCNL)

(TED UOP)

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Tx of Urolithiasis

Abx for infection
Acute tx to relieve obstruction:
- _____
- ______
- (to prevent sepsis / renal damage / loss of renal function)
Later proceed to definitive stone management under more controlled circumstances

ureteral stent placement
nephrostomy tube placement

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ESWL

Decrease ____ function up to 3 weeks
6 complications?

renal perfusion

renal hematoma / retroperitoneal hematoma
Ecchymosis
UTI –> sepsis
Steinstrasse
Ureteral stricture
Pain

3 components of evaluation of urolithiasis

H&P
Labs (creatinine and white count)
Imaging (Stone protocol CT WITHOUT contrast)

_Which tx?_ * **Indications: failure of / contraindications to other modalities** * trial of passage * dissolution * ESWL * Ureteroscopy w/ stone manipulation * PCNL

Open or Laparoscopic Surgery | (not common, is usually last resort)

Which 7 meds can cause urolithiasis?

* Vit C * Vit D * Triamterene precipitation * Protease inhibitors (Indinavir) * Furosemide increases urinary calcium excretion * Acetazolamide (CAI) causes RTA state * Uricosuric agents (probenecid, salicylates)

5 imaging studies

* KUB (Kidney, Ureter, Bladder) * US abdominal / retroperitoneal / renal & bladder * Intravenous Urogram (IVU) (not performed anymore) * CT Stone Protocol (abd/pelvis) WITHOUT contrast * CT urogram (abd/pelvis) WITH contrast, including delayed phase ## Footnote *(if stone protocol is negative, get the CT urogram)*

What are the 2 causes of stones due to anatomy?

* Obstruction * Stasis

**Which stone?** * Precipitated drug, such as \_\_\_\_\_ * Radiolucent * Not visible on stone-protocol CT

**Protease Inhibitor Stone** * Indinavir

A few etiologies of Urolithiasis (8)

* Anatomic * Urine characteristics * Pt volume status * Diet * Metabolic * Disease states * UTI * meds

5 components of metabolic eval to prevent future stones

* H&P * UA * Stone analysis * Serum labs (electrolytes, uric acid, Ca, phosphate, alkaline phosphatase, creatinine) * 24 hour urine collection

**Candidates for "trial of passage"** * Stones \_\_mm or less (68% pass within __ days) * Taking fluids and analgesics PO * Alpha-blocker (\_\_\_) increase passage percentage, decrease time to passage, decrease pain w/ passage * Filter urine (screen / coffee filter) * Periodic imaging to assess for \_\_\_\_.

* 5 * tamsulosin * hydronephrosis

**Which med for Prevention of Future Stones?** * Involved in metabolism of oxalate * Deficiency leads to hyperoxaluria

Pyridoxine (B6)

**ESWL** * If bilateral stone disease, may choose to do what? * If solitary kidney, use what?

* To do each kidney at separate settings * ureteral stent

**Percutaneous Nephrolithotomy (PCNL)** * Access achieved in ____ or \_\_\_\_ * Access through the \_\_\_\_, ____ approach, needle placed under ____ guidance * Needle/catheter advanced to \_\_\_\_\_\_ * Wire, tract dilation * Nephroscopy * Instruments passed under direct \_\_\_ * Energy delivered to \_\_\_\_\_\_ * _____ grasped, removed

* Interventional Radiology or OR * skin / flank / fluoroscopic * renal collecting system * vision * lithotripsy stone * fragments

4 sxs of urolithiasis

* Flank pain * N/V (from the pain) * Hematuria * Hyperkinetic\*\* (common). Pt is moving all over and pacing the room

**9 Complications of Ureteroscopy w/ manipulation (endoscopy)** * Ureteral \_\_\_\_ * Ureteral \_\_\_\_ * Submucosal \_\_\_\_ * Ureteral ____ (1%) * Extrustion of stone outside the lumen of ureter * \_\_\_\_ * \_\_\_\_ * \_\_\_\_\_

* Avulsion * perforation * tunneling * stricture * UTI * Bleeding * Pain

Tx of lower tract stones (2 locations?) * 4 treatments?

**Bladder & urethra** * Cystourethroscopy, cystolitholapxy * Extracorporeal shock wave lithotripsy (ESWL) * Open stone removal (super rare!) Dissolution (meds) - common tx

3 components of **volume status** of pt w/ Urolithiasis

* Volume depletion * Low UOP * Supersaturation of solute

**Which med for Prevention of Future Stones?** * Tx for cystinuria * Increases solubility, prevention of cystine stones * Tiopronin * D-Penicillamine

Thiols

Other 5 names for Urolithiasis

* "kidney stones" * nephrolithiasis * ureterolithiasis * cystolithiasis * calculus / calculi

3 labs

* **UA** (pH, specific gravity, hemoglobin, microscopy) * **CBC** (WBC elevation) * **BMP** (creatinine, BUN, electrolytes)

**_Dissolution (chemolysis) of Uric Acid Stones_** * **Alkalinize urine** * pH greater than \_\_\_ * __ and ___ PO * Can take __ months to work * **Irrigate collecting system** * via \_\_\_\_\_ * sodium bicarb * THAM

* 6.5 * Sodium bicarb & Potassium citrate * 3 * nephrostomy tube

What are the 2 Crystal Inhibitors?

* **Citrate** (complexes w/ calcium) * **Urea** (increases solubility of uric acid)

**Which tx?** * Done in OR under general anesthesia * Transurethral approach * Flexible scope placed up ureter * Energy delivered to calculus * laster lithtripsy * ultrasonic lithotripsy * electrohydraulic lithotripsy (EHL) * Pneumatic impactor "\_\_\_\_\_" * Stone broken up * Fragments basketed out * Possible ____ temporarily

**Ureteroscopy w/ stone manipulation** * "jackhammer" * ureteral stent

**Prevention of Future Stones** * Reduce \_\_\_\_ * High ____ lowers urinary citrate * Animal protein * Limit intake of ____ and \_\_\_\_\_ * ____ and \_\_\_\_\_: low \_\_\_\_\_\_

* PRAL (potential renal acid load) * PRAL * cheese & egg yolks * fruits & veggies

What 2 things = emergency?!

* Fever * Obstructive stones

**Extracorporeal Shock Wave Lithotripsy** * 3 good things about ESWL * 1 bad thing about ESWL

* Outpatient * Non-invasive * Sedation * **Bad:** stone fragments not removed

**Which med for Prevention of Future Stones?** * Corrects acidosis, which increases urinary citrate and decreases urinary calcium * Binds w/ calcium, inhibits calcium crystallization * **SE:** hyperkalemia\*\* & peptic ulcers * **Caution:** Uncontrolled DM, renal insufficiency, delayed gastric emptying, K sparing diuretics * **Dosing:** titrate per urine pH

Potassium Citrate

**Which stone?** * Cause: UTI * Radio-opaque * Forms in alkaline urine * Can be dissolved w/ acidification of urine * Composition of most \_\_\_\_\_\_

**Magnesium ammonium phosphate** (struvite, triple phosphate, MAP) * staghorn calculi

**_Dissolution (chemolysis) of Cystine Stones_** * **Alkalinize urine** * pH greater than \_\_ * ____ PO * **Irrigation of collecting system** * Sodium bicarb * THAM * N-acetylcysteine

* 7.5 * Potassium citrate

**Which stone?** * Associated w/ Proteus UTI * Radiolucent

Matrix

**ESWL (extracorporeal shock wave lithotripsy)** * Stone size \< __ cm * Visible on \_\_\_\_

* 2 * fluoroscopy

4 types of Open / Laparoscopic Surgery

* Cystolithotomy (large stone burden, other concomitant surgery) * Pyelolithotomy * Ureterolithotomy * Anatrophic nephrolithotomy (Brodel's avascular plane)