Transcript Urolithiasis - Liaquat University of Medical & Health Sciences

UROLITHIASIS
Dr Zakir Hussain Rajpar
Assistant Professor Of Urology
Liaquat University Of Medical And Health Sciences
Urolithiasis
Urolithiasis (from Greek oûron-urine and lithos-stone) is
the condition where urinary stones are formed or located
anywhere in the urinary system.
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Background
Urolithiasis
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Kidney stones
Ureteral stones
Bladder stones
Urethral stones
Background
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Urolithiasis is a common
disease that is estimated to
produce medical costs of $2.1
billion per year in the United
States alone.
Urolithiasis has been a part of
the human condition for
millennia and have even been
found in Egyptian mummies.
Background
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Renal colic affects approximately 1.2 million people
each year in USA and accounts for approximately 1% of
all hospital admissions.
Most active emergency departments (EDs) manage
patients with acute renal colic every day
Epidemiology
Epidemiology
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Urolithiasis occurs in all parts of the world
A lifetime risk:
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2-5% for Asia
8-15% for the West
Hot Climate
Dietary habits
Hereditary factors
Epidemiology
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The lower the economic status, the lower the likelihood
of renal stones
Most at 20-49 years
Peak incidence at 35-45 years
Male-to-female ratio of 3:1
Chemical types and
etiology
Chemical Types
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Four main chemical types:
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Calcium stones
Struvite (magnesium ammonium phosphate) stones
Uric acid stones
Cystine stones
Calcium stones
Calcium stones
account for 75%
of Urolithiasis.
 Radio-opaque
 Multiple factors
and etiologies
 Mostly incidental
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Calcium Stone Known
etiologies
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Incidental
Hyperparathyroidism
Increased gut absorption of calcium
Renal calcium leak
Renal phosphate leak
Hperuricosuria
Hperoxaluria
Hypocitraturia
Hypomagnesuria
Calcium Stone
Struvite (magnesium ammonium
phosphate) stones
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Account for 15% of renal calculi
Infectous stones
Gram-negative rods capable of
splitting urea into ammonium, which
combines with phosphate and
magnesium
More common in females
Urine pH is typically greater than 7
Struvite (magnesium ammonium
phosphate) stones
Stag horn stones
are non
obstructive thus
painless
 Slowly growing
 Discovered
incidentally
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Uric acid stones
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Account for 6% of renal
calculi
Urine pH less than 5.5
 High purine intake eg.
organ meats
 legumes
malignancy
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25% of patients have gout
Uric Acid Stones
Uric Acid Stones
Cystine stones
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2% of renal calculi
Autosomal recessive trait
Intrinsic metabolic defect resulting in
failure of renal tubular reabsorption of:
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Cystine
Ornithine
Lysine
Arginine
Urine becomes supersaturated with
cystine, with resultant crystal
deposition
Cystine Stones
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Radio-faint
History
History
The presentation is variable.
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Patients with urinary calculi may report
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Pain
Infection
Hematuria
Asymptomatic
Silent Kidney stones
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Obstructive ureteral stone
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The passage of stones into
the ureter is associated with
classic renal colic because
of:
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subsequent acute obstruction
proximal urinary tract dilation
ureteral spasm
Acute renal colic is probably
the most excruciatingly
painful event a person can
endure
Classic Renal Colic
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Acute onset of severe flank pain radiating to the groin
Gross or microscopic hematuria
Nausea, and vomiting not associated with an acute abdomen in
50%
Staghorn stone
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Staghorn calculi are often
relatively asymptomatic.
Branched kidney stone occupying
the renal pelvis and at least one
calyceal system.
Manifest as infection and
hematuria.
Acute renal failure
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Asymptomatic bilateral
obstruction
Solitary Kidney with
obstructive stone
Location and characteristics of pain
from ureteral stones
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Depends on the level of
obstruction and its degree:
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ureteropelvic junction
pelvic brim
ureterovesical junction
UPJ Stone
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Stones obstructing the
ureteropelvic junction may
present with mild-to-severe
deep flank pain without
radiation to the groin
Ureteral Stone
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Upper ureter
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Mid Ureter
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Cause pain that radiates anteriorly and caudally.
Can easily mimic appendicitis on the right or acute
diverticulitis on the left.
Distal Ureter and UVJ stones
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Cause pain that tends to radiate into the groin or testicle
in the male or labia majora in the female
At the ureterovesical junction also may cause irritative
voiding symptoms mimicking cystitis, such as:
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urinary frequency
dysuria
Pain distribution review
Bladder Stones
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Usually asymptomatic and are passed relatively easily
during urination.
Rarely, a patient reports positional urinary retention
(obstruction precipitated by standing, relieved by
recumbency).
Phases of an attack
Phases of an attack
Physical exam
Physical exam
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Dramatic costovertebral angle
tenderness
unremarkable abdominal evaluation
painful testicles but normal-appearing
constant body positional movements
(eg, writhing, pacing)
Tachycardia
Hypertension
Microscopic hematuria
Diagnosis
Diagnosis
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The diagnosis of nephrolithiasis is often made on the
basis of clinical symptoms alone, although confirmatory
tests are usually performed.
Laboratory tests
Labarotary Testing
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The recommended based on EUA recommendations:
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Urinary sediment/dipstick test: To demonstrate blood cells
Serum creatinine level: To measure renal function
Additional Lab Tests
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May be helpful:
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CBC in febrile patients
Serum electrolyte assessment in vomiting patients
24-Hour urine profile on outpatient basis
Imaging studies
Imaging studies
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Noncontrast abdominopelvic CT scan: The imaging
modality of choice for assessment of urinary tract
disease, especially acute renal colic.
IV contrast and delayed images might be required in
selected cases
Imaging studies
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Renal ultrasonography:
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Renal stone
Hydronephrosis or ureteral dilation
Misses 30 % of stones
Plain abdominal radiograph (flat plate or KUB) misses
40 % of stones
Imaging studies
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Management
Emergency Renal Colic
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IV access to allow :
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Fluid
Analgesics:
 Paracetamol
 NSAID
 Opiod
Antiemetic
In case of infection:
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Urine culture
Blood culture accordingly e.g. febrile
Antibiotics
Approach Considerations
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In emergency settings what should be kept in mind is the
small percentage suffering renal damage or sepsis.
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Evident infection with obstruction
A solitary functional kidney
Bilateral ureteral obstruction
Renal failure
Important
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The most morbid and potentially dangerous aspect of
stone disease is the combination of urinary tract
obstruction and upper urinary tract infection.
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Pyelonephritis
Pyonephrosis
Urosepsis
Early recognition and immediate surgical drainage are
necessary in these situations
Approach Considerations
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The size of the stone is an
important predictor of
spontaneous passage.
A stone less than 4 mm in
diameter has an 80%
chance of spontaneous
passage; this falls to 20%
for stones larger than 8 mm
in diameter
Approach Considerations
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Hospital admission is clearly necessary when any of the
following is present:
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Oral analgesics are insufficient to manage the pain.
Intractable vommiting
Ureteral obstruction from a stone occurs in a solitary or
transplanted kidney.
Bilateral ureteral obstruction
Ureteral obstruction from a stone occurs in the presence of
a urinary tract infection (UTI)
 Fever
 Sepsis
 Pyonephrosis
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Approach Considerations
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Relative indications to consider for a possible admission
include comorbid conditions
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diabetes
dehydration
renal failure
immunocompromised state
perinephric urine extravasation
pregnancy
Clinic Follow up
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Patients who do not meet admission criteria to be
discharged on medical expulsive therapy from the ED in
anticipation that the stone will pass spontaneously at
home.
Arrangements should be made for follow-up with a
urologist in 2-3 days.
Active medical expulsive therapy
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Paracetamol PRN for pain with or without Codeine
NSAID PRN for pain
Oral opiod analogue for severe pain
Alpha blockers
Antiemetic PRN for nausea and/or vommiting
Prednisone 20 mg twice daily for 6 days
With MET, stones 5-8 mm in size often pass, especially if
located in the distal ureter.
Approach
Considerations
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General recommendation not to wait longer than 4
weeks for a stone to pass spontaneously before
considering intervention.
Approach Considerations
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About 15-20% of patients require invasive intervention
eventually as emergency or electively due to:
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stone size
continued obstruction
Infection
intractable pain
Indications for Surgery
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The primary indications for surgical treatment include:
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Pain
Infection
Obstruction
Indications for urgent intervention:
 Obstruction complicated by evident infection
 Obstruction complicated by acute renal failure
 Solitary kidney
 Bilateral obstruction
Surgical options
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Obstruction relief:
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Ureteral stent insertion
Percutaneous nephrostomy
Definitive surgical treatment:
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ESWL
Ureteroscopy
PCNL
Open, laparoscopic and robotic
pyelo-lithotomy, ureterolithotomy,
cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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For an obstructed and infected collecting system
secondary to stone disease
Emergency surgical relief is required with no contraindications:
 percutaneous nephrostomy for critical patients
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ureteral stent placement for stable patients
Surgical options
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The vast majority of symptomatic urinary tract calculi are
now treated with noninvasive or minimally invasive
techniques
Open surgical excision of a stone from the urinary tract is
now limited to isolated atypical cases
Surgical options
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ESWL and ureteroscopy are internationaly recognized as
first-line treatments for ureteral stones.
The 2005 American Urological Association (AUA)
staghorn calculus guidelines recommend percutaneous
nephrostolithotomy as the cornerstone for management
Ureteral Stent
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Guarantees drainage of urine from
the kidney into the bladder and
bypass any obstruction.
Relieves renal colic pain even if the
actual stone remains.
Dilate the ureter, making
ureteroscopy and other endoscopic
surgical procedures easier to
perform later.
Percutaneous nephrostomy
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Indicated if stent placement is
inadvisable or impossible.
In particular patients with
pyonephrosis who have a UTI or
urosepsis exacerbated by an
obstructing calculus
Extracorporeal shockwave lithotripsy
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ESWL, the least invasive of the
surgical methods of stone
removal
Utilizes an underwater energy
wave focused on the stone to
shatter it into passable fragments
It is especially suitable for stones
that are smaller than 2 cm and
lodged in
 the upper or middle calyx
 the upper ureter
Extracorporeal shockwave lithotripsy
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The patient, under varying degrees of anesthesia
The shock head delivers shockwaves developed from an
 Electrohydraulic
 Electromagnetic
 piezoelectric source
Ureteroscopy
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Ureteroscopic manipulation of a
stone is a commonly applied
method of stone removal
A small endoscope, which may be
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Rigid
Semirigid
Flexible
is passed into the bladder and up
the ureter to directly visualize the
stone
Ureteroscopy
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Flexible ureteroscopy allows tackling
of even lower calyceal stones
Stones are fragmented using
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Swiss lithoclast
Laser
Ultrasonic lithotripter
Stones are retrieved using a stone
basket
Percutaneous nephrostolithotomy
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Percutaneous procedures are generally reserved for
large and/or complex renal stones and failures from the
other 2 modalities
Percutaneous nephrostolithotomy is especially useful for
stones larger than 2 cm in diameter
Percutaneous nephrostolithotomy
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In some cases, a combination
of SWL and a percutaneous
technique is necessary to
completely remove all stone
material from a kidney.
Open Surgery
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Open surgery has been used less
and less often since the
development of the previously
mentioned techniques
It now constitutes less than 1% of
all interventions.
Disadvantages include
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longer hospitalization
increased requirements for blood
transfusion.
Long-Term Monitoring
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Metabolic evaluation is done by a typical 24-hour urine
determination of:
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urinary volume
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pH
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specific gravity
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Calcium
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Citrate
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Magnesium
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Oxalate
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Phosphate
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uric acid.
Long-Term Monitoring
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Most common findings are
 Hypercalciuria
 Hyperuricosuria
 Hyperoxaluria
 Hypocitraturia
 low urinary volume
Chemoprophylaxis
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Chemoprophylaxis of uric acid and cystine calculi
consists primarily of long-term alkalinization of urine.
Chemoprophylaxis
Chemoprophylaxis
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Pharmaceuticals that can bind free cystine in the urine:
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D-penicillamine
2-alpha-mercaptopropionyl-glycine
Help reduce stone formation in cystinuria.
Captopril has been shown to be effective in some trials
Dietary Measures
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In almost all patients in whom stones form, an increase in
fluid intake and, therefore, an increase in urine output is
recommended.
This is likely the single most important aspect of stone
prophylaxis
The goal is a total urine volume in 24 hours in excess of
2 liters.
Dietary Measures
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The only other general dietary guidelines are to avoid
excessive salt and protein intake.
Moderation of calcium and oxalate intake is also
reasonable
Beware to advice moderation not avoid calcium intake as
it will result in calcium deficiency disorders, most
importantly osteoperosis.
Thank you
References
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