Investigations and Management of UrolithiasisAmalina Mohd Daud (0917298)

Outline of Presentation

• Investigations

• Basic Laboratory: Urine and Blood

• Imaging: KUB Xray, Ultrasound, IVU and CTU

• Radionuclide study: DTPA scan

• Management

• Preventions

Urine

• UFEME

• Urine culture

• 24 hour urine collection

Urine

• UFEME

• Red cells (microscopic hematuria)

• White cells (infection)

• Nitrite (infection)

• Approximate pH (N: 5.8-6.2)

• Specific Gravity (hydrational status)

• Urine culture –presence of urea splitting organisms

• Urine microscopy

• 24 hour urine collection –creatinine clearance, volume

- measure Mg, Na, uric acid, oxalate, citrate, phosphate

Cystinuria Struvite calculi Calcium oxalate

Hexagonal crystal Rectangular ‘coffin-lid’ crystal

Tetrahedral envelope crystal

Blood

• FBC (anemia of chronic disease, CKD)

• Renal Profile

• Urea and creatinine

• Uric acid

• Calcium (high investigate further for hyperparathyroidism)

• Sodium

• Potassium (low: suspect distal RTA)

• CRP

• Coagulation Profile (if intervention was planned)

Imaging: Plain KUB X-rays

• Not useful

• Radioluscent stone

• Stone <4mm

• Lies over sacrum/bony structures

• Bowel gas can obscure its efficacy

• Cannot differentiate

• Stones

• Calcified LN

• Phleboliths

• Sensitivity: 50-70%

75% radiopaque

KUB X-ray

Click icon to add picture

Imaging: KUB Ultrasound

• Sensitivity to detect renal calculi ~95% (complement KUBXR)

• Very sensitive to detect obstruction and radioluscent stone

• Non-invasive

• May miss small stone (<5mm) and ureteral stone

• Particularly important in pregnant women

KUB Ultrasound

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- Dilated ureteral tunnel

- Stone and shadowing distal to the stone

Imaging: IVU

• Provide anatomical and functional informations

• Size and location of the stone

• Presence and severity of obstructions

• Renal and ureteral abnormalities

Imaging: IVU

Indications

• Urolithiasis/nephrolithiasis

• Suspected urinary tract pathology

• Repeated infections

• Idiopathic hematuria

• Investigate uncontrolled HPT in young adults

• Renal colic

• Trauma

• VUR

Contraindications

• General contraindications to water soluble contrast agents

• Hepatorenal syndrome

• Thyrotoxicosis

• Pregnancy (allow 28 days from childbirth)

• Blood urea raised about 12mmol/L

Preliminary FilmLook for radiopaque stone before contrast injected

Immediate FilmNephrogram

5 minute film-Determine symmetrical excretion

- Determine need for more contrast

15 minute film

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Delineate pelvicalyceal junction and ureter

Release / 25 minute filmDemonstrate distended bladder

Post-Micturition Film-demonstrate bladder emptying success

-demonstrate return of dilated upper urinary tract with relief of bladder pressure

Imaging: CT-urography

• Evaluate kidney, ureter and bladder

• Not require any bowel preparations

• Faster than IVU

• Radiation dose higher than IVU

- Use CT protocol for patient under age 40

Imaging: CT-Urography

Indications

• Urinary calculi

• Hematuria

• Flank and abdominal pain

• Renal and urothelial neoplasm

• Congenital anomalies of kidney and ureter

Contraindications

• Renal insufficiency

• Prior severe reaction

• pregnancy

Non-contrast-Evaluate for calculi, fat-containing lesions and parenchymal calcifications

- Stone in middle segment of right ureter

Radionuclide study : DTPA

• Diethylene triamine pentaacetic acid

• Evaluate obstruction, perfusion, GFR quantifications

• Adv: relative split function of both kidney

DTPA

Relative split function

How to Investigate Urolithiasis??

Urine- UFEME- Urine C+S- 24 hour urine

collection

Blood- FBC- Renal Profile

Imaging- KUB X-ray- KUB Ultrasound- IVU

Plan for Intervention- DTPA If IVU contraindicated

- CTU

Management

Initial Management• IV access for fluid, analgesics and antiemetics

• Analgesics: • NSAIDS (Voltaren)

• avoid Morphine – provoke/ prolong ureteric spasm and pain

• Antibiotics : IV cefuroxime 1.5mg TDS if infection

• Imaging

Evidence of Obstruction or Infections?

• Complete obstruction of ureter (IVU, CTU)

• Infection above the obstructing stone

• Aim: prevent renal damage

• Options:

• Percutaneous nephrostomy

• Ureteral stent placement

• Endoscopic removal of stone

Ureteral Stent Placement

• Relieve obstruction and infection of ureter

• Primary choice due to less invasiveness and less bleeding risk

• Allow urine drainage and improve renal colic

• Cx: blocked, kinked, dislodged and infected

Percutaneous Nephrostomy Tube• Choice of treatment if stent cannot be placed percutaneously or require

future percutaneous treatment of stone burden

• Temporary urinary diversion

• Contraindicated:

• Bleeding diasthesis

• Uncooperative patient

• Severe hyperkalemia (>7mEq/L)

• Complications

• Bleeding

• Sepsis

• Injury to other organs

Endoscopic Removal of Stone

No evidence of obstruction or infectionObservation Surgical

- stone <5mm

- Asymptomatic patients

• persistent, recurrent or severe pain

• Obstruction or infection

• Risk of pyonephrosis and urosepsis

• Solitary kidney

• Bilateral obstruction

No evidence of Obstruction or InfectionLocation <5mm 5-10mm 1-2cm >2cm

Urethra Pass spontaneously

Open Vesicolithotripsy

Bladder Pass spontaneously

Transurethral Cystolitholapaxy

Ureter MET URSESWLMET

URSESWL

URSOpen/ Laparoscopic uretherolithotomy

Kidney MET ESWLRIRSMET

ESWLRIRS

PCNL

# At any size, chemolysis is important

ChemolysisStone Chemolysis

Calcium -least amenable of stone- Strong acid for stone to dissolve (not safe for human)

Struvite stone - Soluble in acid condition- Rx: Acetohydroxamic acid (AHA) 250 mg TDS (irreversible

urease inhibitor)- AE: hemolytic anemia, neurosensory deficit and

thrombophlebitis

Uric acid stone -soluble in alkaline condition- Rx: Na bicarbonate 650mg-1g TDS/QID (urine alkalinization) Acetazolamide 250-500mg ON (carbonic anhydrase inhibitor)

Cystine stone -soluble in alkaline condition-Rx: (D-penicillamine 1-2mg/d OR a-mercaptopropionylglycine OR acetylcysteine ) + Na bicarbonate

MET

• Nephrolithiasis: 3-8 mm

• Likelihood of 65% for stone passage

• Conservative management: oral/iV hydration + analgesics, + medications that promote stone passage

• Rx: Tamsulosin (a-blocker), Nifedipine

• Relaxes the intramural smooth muscle of ureter urine and stone passage

• Controversial: safety?? – use as off label

Bladder stone

• Options

• Transurethral cystolitholapaxy

• Percutaneous suprapubic cystolitholapaxy (paeds)

• Method

• Cystoscope fragment stone stone remove via cystoscope

Extracorporeal Shockwave Lithotripsy (ESWL)

• Underwater energy wave shatter stone into passable fragments

• Fragments pass down through ureter ureteric colic (diclofenac)

• Indications

• stone <2cm

• Upper and middle ureter; kidney

• Contraindications

• Pregnant mother

• Untreatable bleeding diasthesis

• Impacted stone

• Ureteral obstruction distal to the stone

• Complications

• Ureteric obstructions (bulky fragments) ureteral stent prior to ESWL

• Urosepsis prophylactic antibiotic prior to ESWL (currently not needed)

Uteroscopic Lithotripsy (URS)

• Endoscopic: pass ureteroscope fragment stone stone pass / wire basket to fish out stone

• Advantage: remove hard stone, ureteral dilatation

• Can be performed in patient with bleeding diasthesis

• Contraindications: untreated UTI

• Complications (rare)

• Hematuria

• Ureter perforation

• Stone migration

• First choice for ureteral stone >10mm• First choice for distal ureteral stone

<10mm other than ESWL

Open/ Laparoscopic Urolithotomy

• Indications

• Complex stone burden : multiple, impacted ureteric stone

• Treatment failure

• Morbid obesity

• Skeletal abnormalities

• Plan for partial nephrectomy and nephrectomy

• Patient’s choice

• Stone in ectopic kidney

Retrograde Intrarenal Surgery (RIRS)

• Indications

• Failed ESWL

• Lower calyx stone

• Concomittant ureteric and kidney stone

• Bleeding disorders, unfit for anesthesia

• Gross obesity

• Need for complete stone removal . Eg: pilot

• Complications: rare

• Guide wire pass and ureteral dilate flexible ureteronoscope irrigate lithotripsy stone retrieve with basket ureteral stent placement

Percutaneous Nephrostolithotomy (PCNL)• Indications

• Renal stone >2cm

• Staghorn calculi

• Failed / contraindicated for ESWL

• Contraindications

• Uncorrected bleeding diasthesis

• Untreated UTI

• Complications

• Perforation of collecting systems

• Perforation of colon or pleural cavity

• Hemorrhage from punctured renal parenchyma

Placement of hollow needle into collecting system

fragmented remove stone/ allow drainage

Prevention

Preventions

Thank you =)