Transcript Renal tract stones - Surgical Students Society of Melbourne

RENAL TRACT STONES
Lachlan Brennan
Since the Stone Age
“I will not cut persons
laboring under the stone,
but will leave this to be
done by men who are
practitioners of this work”
Hippocrates 400BC
Pain
Agony
Misery
“Kidney stones”
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Litho = stone
Urolithiasis = stone in the
urinary tract
Nephrolithiasis = stone in renal
calyces/pelvis
Ureterolithiasis = stone in ureter
Cystolithiasis = stone in bladder
Calculi = stone
Formation
Solvent
Solute
Crystals
Inhibitors
Anatomical anchor: Renal calyces, PUJ, VUJ
Chemical composition
Stone type
Frequency
Stone forming conditions
Calcium
oxalate/calcium
phosphate
80%
High calcium/oxalate/phosphate
concentration in urine
Uric acid
5%
Hyperuricaemia and/or hyperuricosuria
**radiolucent stone
Cystine
1%
Genetic disorder, cystine leaks through
glomeruli
Struvite
10-15%
Infection with urea splitting bacteria
Proteus mirabilis, Proteus vulgaris
Other
Rare
Specific metabolic disorders, medications,
History
Epidemiology
 Lifetime prevalence 10-15%
 Uncommon before age 20, peak 40s-60s, bimodal
in women
 Male > female 3 : 1
Sudden onset, unilateral flank pain
 Radiation specific to site of stone –
abdomen/back, groin/gonads, urethra
 Haematuria, nausea & vomiting
Risk factors
Risk factors
Genetic/Anatomical Disease processes
Environment
Family history (2.5x)
Cystinuria
Horseshoe kidney
Calyceal diverticulum or cyst
Ureteral stricture
Vesicoureteric reflux
Ureterocoele
Low fluid intake
Hot weather
High sodium diet
High oxalate diet
Primary hyperparathyroidism
Gout
Crohn’s disease
Hyperthyroidism
Multiple myeloma
Sarcoidosis
Obesity
Hypertension
Medications: loop diuretics,
thiazide diuretics
Pregnancy
Personal history
 Napoleon, Isaac Newton, Benjamin Franklin, Lyndon Johnson
Examination
Signs of renal colic
 Unilateral flank tenderness (unreliable)
 No peritonism
Signs of complications
 Fever, dehydration
Differential diagnoses
 Pyelonephritis, appendicitis, diverticulitis, salpingitis,
ectopic pregnancy, AAA, testicular torsion, herpes
zoster, biliary disease, renal cell carcinoma
Investigation
Pathology
 In all – UEC, FBE, urine dipstick/MC&S, BhCG
 In some – ionised calcium, uric acid, PTH, urinary products
Imaging
 Plain XR
 CTKUB
 Renal tract ultrasound
 Intravenous pyelogram
Lucent
Urate
Cystine
Struvite
Calcium
oxalate/p
hosphate
Opaque
When to call Urology?
Does surgery need to be considered?
Complicated vs. Uncomplicated
 Large stone
 Bilateral stones with obstruction
 Evidence of shock or infection
 Acute renal impairment
 Anuria/oliguria
 Solitary kidney, transplanted kidney
 Pregnancy
Medical management
Analgesia
 NSAIDs (diclofenac, indomethacin) and opiates are
roughly equivalent, can use both
Anti-emesis
Medical expulsive therapy
 Tamsulosin (alpha-antagonist)
Oral chemolysis
Antibiotics for infection
Prevention
 Allopurinol for urate stones, dietary restriction of
calcium/oxalate
Wait and watch
Spontaneous expulsion
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Size of stone (mm)
Rate of expulsion
1
2-4
5-7
7-9
>9
87%
76%
60%
48%
25%
Serial imaging, urine straining
Symptom management
Monitor for complications
Surgical management
Non-invasive approach
 External shock wave lithotripsy
Incisional approach
 Percutaneous lithotomy
 Open/laparoscopic surgery
Endoscopic approach
 Ureteroscopy and basket
Ureteric stent placement
Review
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Common ED presentation
Clues on history and examination
Confirmation with investigation
Complicated vs. Uncomplicated
Call Urology
Consider medical as well as surgical Mx