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17th European Urology Residents Education Programme > Urolithiasis > Flashcards

Urolithiasis Flashcards

1
Q

What is the two tumb rules when it comes to positioning of laser fibers in the urether?

A

Aim at 1/4 of the diameter of the stone

When you see the fiber your scope is safe

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2
Q

When was ESWL approved for urolithiasis?

A

1986

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3
Q

Indications for ESWL

A

non obese patient
stones ≤ 2 cm
pelvic stones
stone in upper and middle calyceal groups

less effective on ureteral stones

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4
Q

What are “hard stones”?

A

Density >1000 HU

Calcium oxalate
monohydrate
cystine
brushite

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5
Q

Prognostic factors for successful ESWL-treatment:

A 
Number of stones
Lower pole?
Composition (<1000 HU?)
UT Anatomy
BMI >30
Duration of obstruction
Available equpment
Experience of operator
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6
Q

What are the benefit of ESWL for pediatric patients?

A 
minimally invasive
high stone free rates
easier passage of fragments
low complication rate
no renal damage
need for stenting rare
  • general anasthesia in children < 10 years
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7
Q

Contraindications for ESWL:

A 
Preganancy
Anticoagulants
Uncontrolled urinary infection
Severe skeletal anomalies
Morbid obesity
Arterial anerurysm (in the vicinity)
Anatomical obstruction distally to the stone
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8
Q

ESWL-complications:

A 
Steinstrasse 4-7%
Development of the residual stones 21-59%
Renal colic 2-4%
Infection (sepsis 1-2,7%)
Concussion 
Hematuria
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9
Q

What is the use for double J-stents in ESWL?

A

Prevents obstruction and colic

Does not reduce steinstrasse and infections

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10
Q

What is the effect of α1-blockers on ureteral lithiasis?

A

Reduction of time for the expulsion of fragments
Reduction of the renal colic episodes
Increase of SFR

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11
Q

When should antibiotics be used in prophylaxis for ESWL?

A

Internal stent placement
Increased bacterial burden (nephrostomy tube, indwelling catheter, infectious stones)
Positive culture

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12
Q

What are the biggest risk factors for kidney stones?

A

Male
Caucasian
Old age
Overweight/obese

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13
Q

Name 3 non-infectious stones:

A

Calcium oxalate
Calcium phosphate
Uric acid

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14
Q

Name 3 infectious stones:

A

Magnesium ammonium phosphate
Carbonate apatitie
Ammonium urate

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15
Q

Name 3 stones caused by genetic disorders:

A

Cystine
Xantine
2,8-Dihydroxyadenine

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16
Q

How are kidney stones mostly composed (in %)?

A 
calcium-based 78-85%
uric acid 5-10%
struvite 1-4%
cystine 1%
drugs/metabolites <1%
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17
Q

Name 3 kidney stones caused by drugs:

A

Indinavir
amoxicillin
ciproloxacin

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18
Q

When should stone analysis be performed?

A

First stone

and

recurrent stones despite drug therapy
early recurrence after complete stone clearance
late recurrence after long stone-free period because composition may change

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19
Q

What health risk factors is urolithiasis associated with?

A 
diabetes
obesity
metabolic syndrome
osteoporos
cardiovascular pathologies
renal failure
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20
Q

What is the stone recurrence rate at 2, 5, 10 and 15 years?

A

11%
20%
31%
39%

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21
Q

How common is hightly recurrent stone disease?

A

~10%

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22
Q

When taking a medical history of a stone forming patient what should be included?

A

Stone history
Dietary habits
Medication charts

heredity
IBD
malignancies
gout
obesity
diabetes
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23
Q

What diagnostic imaging should be performed on a stone forming patient?

A

Ultrasound
Enhanced helical CT
Determination av Hounsfield units

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24
Q

What blood analysis’ should be performed on a stone forming patient?

A

Creatinine
Calcium
Uric acid

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25
What urine analysis' should be performed on a stone forming patient?
``` pH dipstick test urine culture microscopy of urinary sediment cyanide nitroprusside test (cystine) ``` 2 x 24 hour collection any time for noobstructing stones, > 6 weeks after stone removal/passage
26
What should stone forming patientes be adviced when it comes to fluid intake?
Aim for urine volume >2,5L
27
What are the dietary recommendations for stone forming patients?
``` Normal calcium intake Low sodium (Na(Cl) Low animal protein intake Low fat intake Moderate oxalate intake Reduce simple sugar intake Eat vegetables and fruit ``` Fluids for urine volume >2L
28
What causes Uric acid stones?
LOW URINE PH + HYPERURICOSURIA insuline resistance excess purine intake metabolic syndrome proliferative syndromes obesity gout type 2 diabetes type 2 diabetes diarrhea uricosuric drugs
29
How do you treat Uric acid stones?
``` Increase fluid intake Urine alkalinization (Potassium citrate) Decrease protein intake Decrease sugar intake Allopurinol ```
30
Why is hypocitraturia bad?
Acidic pH consumes citrates and favour calcium oxalate stones Citrate is a potent inhibitor of cristallization
31
What can Thiazides cause? | and by what mechanism?
Hypoctiraturia Thiazides --> hypokalemia ---> intracellular acidosis---> inhitibs synthesis and promotes citrate reabsorption into the cell =treat hypokalemia (Potassium=Kalium)
32
Name a source of potassium that can lower the risk for stone disease?
Orange juice | cranberry and grapefruit juice can increase the risk
33
What can cause Hyperoxaluria?
Increased oxalate intake High urinary concentration because of low urine volume Reduced calcium intake (calcium decreases oxalate absorbtion)
34
How do you treat Hyperoxaluria?
``` Increase fluid intake Eat less oxalates and fat Increase calcium intake Vitamin B6 Correction of bowel pathology when possible ```
35
What can cause Hypercalciuria?
``` Low diures High calcium intake High protein intake High salt intake Metabolism ```
36
How do you treat Hypercalciuria?
More fluids Limit calcium intake Limit protein intake Limit salt intake Thiazide diuretics---> increase calcium reabsorption OBS give potassium supplementation to prevent Hypokalemia and hypocitraturia
37
What can cause Cystine stones?
``` Low diures Low urinary pH High urinary cystine levels -high methionin food (parmesan, eggs, horse-meat...) -high protein intake -high salt intake ```
38
How do you treat Cystine stones?
``` Increase fluid intake Alkalinization (potassium citrate) Medicate with Tipronine (breaks cystine in two) Lower intake of methionin Reduce protein intake Reduce salt intake ```
39
How do you treat infectous stones?
Remove stone | Treat UTI
40
Does position of the patient matter when performing PNL?
More a preference of the surgeon
41
Why is a posterior calyx preferable for acess when perorming PNL?
There is an avascular fielt known as Brodels bloodless line between the anterior and posterior divisions
42
What is the risk when using balloon dilators for access when performing PNL?
They can dislocate the stone out of the system
43
What are the major complications of PCNL?
``` Rupture of collecting system Hemorrhage Pleural injury Injury to adjacent organs Fever and sepsis ```
44
PCNL stands for:
Percutaneous Nephrolithonomy also PNL
45
What are the indications for open or laparoscopic surgery for stones?
``` Anatomical abnormalities: -horseshoe kidneys -malrotated kidneys -UPJO with stones -ectopic kidneys Stones in symptomatic diverticula When other treatment options are unavailable or have failed ```
46
How often should a stone that has not been treated be checked?
Every 6 months initially, than yearly
47
What is mandatory before endoscopic stone treatment?
Urine culture/microscopy Treatment of UTI Peri-operative antibiotic prophylaxis
48
What is the mean ureteral diameter?
10F
49
What is the mean ureteral length?
30 cm
50
How much better are digital systems for endoscopic stone removal?
saves 20-25% of time
51
What is normal renal pelvic pressure (RPP)?
5-15 mm Hg
52
When will you damage the fornix with elevated renal pelvic pressure?
At 80-100 mm Hg
53
What does elevated renal pelvic pressure (RPP) cause?
epithelial damage resorption of irrigation fluid (containing bacteria and endotoxins) pyelo-interstitial or pyelo-lymphatic/pyelo-tubular reflux--> nephrotic damage ---> renal scarring
54
Late complications of URS:
ureteral stricture | persistent vesicoureteral reflux
55
Early complications of URS:
ureteral stripping guidewire under the mucosa perforation mucosal injury etc ``` hypothermia bleeding push up of the stone hematuria renal colic fewer or urosepsis ```
56
Problems with stents:
``` Stent related symptoms Encrustation Infection Migration Hyperplastic reaction Extrinsic mechanical pressure Long-term patency ```
57
What is different with stents in pregnant women?
A higher tendency for ureteral sten ecrustation | Change stent every 2 months
58
Symptoms from stents:
Frequency Dysuria Urgency Suprapubic pain
59
What is the depth of penetration of a Ho:YAG-laser?
0,4 mm
60
What is true for Retropulsion and stone treatment using Ho:YAG-laser?
More energy = more Retropulsion
61
What are the settings for DUST-vaporisation?
Long Pulse 800 µsec Low Energy 0,5 J High Frequency 15-10 Hz
62
What are the settings for Fragments?
Short Pulse 200 µsec High Energy 1,5-2 J Low Frequency 5 Hz
63
What is the Moses technology?
The laser emits part of the energy to create an initial bubble, the remaining energy is discharged once the bubble is formed, so that it can pass through the already formed vapor channel
64
Is bigger laser fibres better?
No size does not affect fragmentation efficiency small fibres gives less retropulsion small fibres gives more space in the working channel
65
Should laser fibres be stripped or unstripped?
Better performance if stripped
66
When is the laser fibre most damaged?
Hard stones High energy Short pulse duration

17th European Urology Residents Education Programme (17 decks)

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