Renal tract stones - Surgical Students Society of Melbourne
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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”
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
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
Common ED presentation
Clues on history and examination
Confirmation with investigation
Complicated vs. Uncomplicated
Call Urology
Consider medical as well as surgical Mx