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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
Q

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

A 
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

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26
Q

What should stone forming patientes be adviced when it comes to fluid intake?

A

Aim for urine volume >2,5L

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27
Q

What are the dietary recommendations for stone forming patients?

A 
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
Q

What causes Uric acid stones?

A

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
Q

How do you treat Uric acid stones?

A 
Increase fluid intake
Urine alkalinization (Potassium citrate)
Decrease protein intake
Decrease sugar intake
Allopurinol
30
Q

Why is hypocitraturia bad?

A

Acidic pH consumes citrates and favour calcium oxalate stones

Citrate is a potent inhibitor of cristallization

31
Q

What can Thiazides cause?

and by what mechanism?

A

Hypoctiraturia

Thiazides –> hypokalemia —> intracellular acidosis—> inhitibs synthesis and promotes citrate reabsorption into the cell

=treat hypokalemia

(Potassium=Kalium)

32
Q

Name a source of potassium that can lower the risk for stone disease?

A

Orange juice

cranberry and grapefruit juice can increase the risk

33
Q

What can cause Hyperoxaluria?

A

Increased oxalate intake
High urinary concentration because of low urine volume
Reduced calcium intake (calcium decreases oxalate absorbtion)

34
Q

How do you treat Hyperoxaluria?

A 
Increase fluid intake
Eat less oxalates and fat
Increase calcium intake
Vitamin B6
Correction of bowel pathology when possible
35
Q

What can cause Hypercalciuria?

A 
Low diures
High calcium intake
High protein intake 
High salt intake
Metabolism
36
Q

How do you treat Hypercalciuria?

A

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
Q

What can cause Cystine stones?

A 
Low diures
Low urinary pH
High urinary cystine levels
-high methionin food (parmesan, eggs, horse-meat...)
-high protein intake
-high salt intake
38
Q

How do you treat Cystine stones?

A 
Increase fluid intake
Alkalinization (potassium citrate)
Medicate with Tipronine (breaks cystine in two)
Lower intake of methionin
Reduce protein intake
Reduce salt intake
39
Q

How do you treat infectous stones?

A

Remove stone

Treat UTI

40
Q

Does position of the patient matter when performing PNL?

A

More a preference of the surgeon

41
Q

Why is a posterior calyx preferable for acess when perorming PNL?

A

There is an avascular fielt known as Brodels bloodless line between the anterior and posterior divisions

42
Q

What is the risk when using balloon dilators for access when performing PNL?

A

They can dislocate the stone out of the system

43
Q

What are the major complications of PCNL?

A 
Rupture of collecting system
Hemorrhage
Pleural injury
Injury to adjacent organs
Fever and sepsis
44
Q

PCNL stands for:

A

Percutaneous Nephrolithonomy also PNL

45
Q

What are the indications for open or laparoscopic surgery for stones?

A 
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
Q

How often should a stone that has not been treated be checked?

A

Every 6 months initially, than yearly

47
Q

What is mandatory before endoscopic stone treatment?

A

Urine culture/microscopy
Treatment of UTI
Peri-operative antibiotic prophylaxis

48
Q

What is the mean ureteral diameter?

A

10F

49
Q

What is the mean ureteral length?

A

30 cm

50
Q

How much better are digital systems for endoscopic stone removal?

A

saves 20-25% of time

51
Q

What is normal renal pelvic pressure (RPP)?

A

5-15 mm Hg

52
Q

When will you damage the fornix with elevated renal pelvic pressure?

A

At 80-100 mm Hg

53
Q

What does elevated renal pelvic pressure (RPP) cause?

A

epithelial damage
resorption of irrigation fluid (containing bacteria and endotoxins)
pyelo-interstitial or pyelo-lymphatic/pyelo-tubular reflux–> nephrotic damage —> renal scarring

54
Q

Late complications of URS:

A

ureteral stricture

persistent vesicoureteral reflux

55
Q

Early complications of URS:

A

ureteral stripping
guidewire under the mucosa
perforation
mucosal injury etc

hypothermia
bleeding
push up of the stone
hematuria
renal colic
fewer or urosepsis
56
Q

Problems with stents:

A 
Stent related symptoms
Encrustation
Infection
Migration
Hyperplastic reaction
Extrinsic mechanical pressure
Long-term patency
57
Q

What is different with stents in pregnant women?

A

A higher tendency for ureteral sten ecrustation

Change stent every 2 months

58
Q

Symptoms from stents:

A

Frequency
Dysuria
Urgency
Suprapubic pain

59
Q

What is the depth of penetration of a Ho:YAG-laser?

A

0,4 mm

60
Q

What is true for Retropulsion and stone treatment using Ho:YAG-laser?

A

More energy = more Retropulsion

61
Q

What are the settings for DUST-vaporisation?

A

Long Pulse 800 µsec
Low Energy 0,5 J
High Frequency 15-10 Hz

62
Q

What are the settings for Fragments?

A

Short Pulse 200 µsec
High Energy 1,5-2 J
Low Frequency 5 Hz

63
Q

What is the Moses technology?

A

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
Q

Is bigger laser fibres better?

A

No size does not affect fragmentation efficiency
small fibres gives less retropulsion
small fibres gives more space in the working channel

65
Q

Should laser fibres be stripped or unstripped?

A

Better performance if stripped

66
Q

When is the laser fibre most damaged?

A

Hard stones
High energy
Short pulse duration

17th European Urology Residents Education Programme (17 decks)

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