BEDAH Nephrolithiasis
description
Transcript of BEDAH Nephrolithiasis
Urology Division, Surgery DepartmentMedical Faculty,
University of Sumatera Utara
References
Epidemiology
Prevalence of kidney stone 1 – 15 %, and in hot
area such as the mountains, desert & tropical areas
: = 2 to 3 : 1, peak age onset 40 - 60 yrs
The third most common affliction of the urinary tract,
after UTI and pathologic conditions of the prostate
Race : Whites > Asian > African
Individual occupations eg. manager and professional
risk of stone (unclear reason)
Epidemiology25% stone formers have a family history
Risk of stone correlates with weight and body mass index
Uric acid and Ca stones more frequent in, infectious stones more common in
The most common kinds of stones are calcium oxalate, uric acid, struvite and cysteine
Etiology
1. Definitive causes :
Metabolic
Infection
Anatomic
Functional
2. Idiopathic
Definitive causes
Defects in purine metabolism (uric acid related disorders)
Hyperoxaluric states
- Primary hyperoxaluria
- Enteric hyperoxaluria
Hypercalcemic states
- Primary hyperparathyroidism
- Hyperthyroidism
- Vitamin D abuse
Hypercalcemic states (cont.)
- Immobilization
- Disseminated malignancies
- Sarcoidosis
- Renal tubular acidosis
Chronic diarrheal states
Cystinuria
Urinary infection with urease producing microorganisms
Anatomical and functional abnormalities
Risk factors Genetics : Cystinuria : autosomal recessive RTA (renal tubular acidosis) – type IMedullary sponge kidney
Geography : temperature & humidity
Diet : calcium / oxalate intake >>
Profession : sedentary
ClassificationDefenition
Non Calcium Stones Infection stones: • Magnesium ammonium phosphate • Carbonate apatite • Ammonium uratea
Uric acidAmmonium urateaSodium uratea
Cystine
Calcium Stones
Stone Composition and Relative Occurrence
Stone Composition Occurrence (%)
Calcium-Containing Stones
Calcium oxalate 60
Hydroxyapatite (CaPO4) 20
Brushite 2
Non–Calcium-Containing Stones
Uric acid 7
Struvite 7
Cystine 1–3
Triamterene <1
Silica <1
2,8-Dihyroxyadenine <1
Stone formation
Stone formation
Crystallization NucleationAggregation
Inhibitors and Promoters of Crystal Formation
Inhibitors : Nephrocalcin Uropontin Tamm-Horsfall protein Citrate Magnesium
Promoters : Calcium phospate Calcium oxalate
Urinary tract stone
Age Sex
Profession Nutrition Climate Race
Inheritance
Abnormal renal morphologyDisturbed urin flow UTIMetabolic abnormalGenetic factors
Increaseexcretion of : 1.Stone forming constituents2. Crystallization promoters
Decrease :1.Urinary volume2. Excretion of crystallization inhibitors
SUPER SATURATIONSTONE
Pathogenesis
CALCIUM STONES
1. Hipercalciuria
2. Hiperoksaluria
3. Hiperuricosuria
4. Hipositraturia
5. Hipomagnesuria
URIC ACID STONES 5-10% of all stone
3 factors of uric acid stone formation :
1. Low pH, < 5,5
2. Low urine volume
3. Hyperuricosuria urinary uric acid
less than 600 mg/day
Secondary causes : gout (20%),obesity ,
myeloproliferative cancer and congenital
disorder
STRUVITE STONESInfection stones comprise 5% to 15% of all stones Composed of Mg ammonium phosphate crystals
or triple phosphate stoneStaghorn calculi are typically struvite stoneCaused by infection with urease-producing bacteria
:
- proteus is the most common
- urease hydrolized urea to form ammonia
alkalinizes the urine, pH and allows crystals to form
CYSTINE STONES
1% of all stones
Congenital disorders, autosomal recessive
Caused by a defect in cystine reabsorption in
the proximal tubule
Cystine poorly soluble at normal pH (pKa 8.3)
Crystal form benzene ring on microscopy
CALCIUM PHOSPHATE STONE Urine pH > 5.5
Hypocitraturia
70% of adults with type 1 RTA have stones
80% are women
Associated with renal cyst
Medications That directly Promote Stone Formation
Indinavir Stones
Triamterene Stones
Guaifenesin and Ephedrine
Silicate Stones
Anatomic Predisposition
Ureteropelvic Junction Obstruction :
20 % cases
Horseshoe Kidneys
Caliceal Diverticula
DIAGNOSIS
History
Physical examination
Additional :
● Urine, microbiology
● Serum : kidney function, uric acid
● Plain x-ray / USG /IVP
Recently : Computed tomography (CT),
Magnetic resonance imaging (MRI), and
endourology
HISTORY
The chief complaint is a constant reminder to the urologist as to why the patient initially sought care
In obtaining the history of the present illness, the duration, severity, chronicity, periodicity, and degree of disability are important considerations
Indications for a Metabolic Stone Evaluation
Recurrent stone formers
Strong family history of stones
Intestinal disease (particularly chronic diarrhea)
Pathologic skeletal fractures
Osteoporosis
History of urinary tract infection with calculi
Indications for a Metabolic Stone Evaluation
Personal history of gout
Infirm health (unable to tolerate repeated
stone episodes)
Solitary kidney
Anatomic abnormalities
Renal insufficiency
Stones composed of cystine, uric acid, or
struvite
Basic Metabolic Evaluation
HISTORY : Hyperparathyroidism or
hypercalcaemia, Hyperuricemia, Renal
tubular acidosis
X-RAY
STONE ANALYSIS : Ca, Uric Acid,
Cystein, Carbonate etc.
BLOOD : Serum Creatinin, Calcium, Uric
Acid
Basic Metabolic EvaluationURINE :Urinary sediment/dipstick test for :
- Red cells- White cells- Bacteriuria (nitrite)- Urine culture in case of a possible
bacteriuria- pH
CLINICAL PRESENTATION
PAINClassically : flank pain, often acute in onsetLocated in the ipsilateral costoverteral angelCaused by distension of renal capsuleMay radiated to upper abdomen, umbilicus, testis or labiumPain by ureteral obstruction is typically colicky in nature and intensifies with ureteral peristalsis
PAIN
Associated with gastrointestinal symptoms
Ureteral pain is usually acute and secondary to
obstruction
Site of ureteral obstruction different referred
pain
- Right mid ureteral stone McBurney”s point
- Distal ureteral stones Ipsilateral groin,
testicular (can mimic torsion or epididimytis),
vulvar
pain, supra pubic, urethra and tip of penis
PAIN
- waxes & wanes - frequently move about to find a more comfortable position
Sudden onset, no relief with change of position
CLINICAL PRESENTATION
Nausea & vomiting
Irritative voiding symptom
Hematuria (gross or microscopic)
Urinary infection
Fever, esp if infection present
Occasionally asymptomatic, with stones
detected incidentally
PHYSICAL EXAMINATION
1. Inspection : General overview of patient Local position ?? Systemic component tachycardia, sweating
and nausea
2. Palpation :Bimanual palpation of the kidney abdominal massDRE : To exclude other patological conditions
URINALYSIS AND URINE CULTURE
RBC usually present, WBC may be presentpH : < 5.5 + radioluscent stone uric acid stone
> 5.5 + metabolic acidosis, hypokalemia & hyper chloremia RTA > 6.0 struvit
Crystals : - Ca oxalate dumbbell/hourglass/bipyramidal
- Ca phosphate needle-shaped/amorphous - uric acid amprphous/rosettes - struvite coffin lid - cystine benzene ring/hexagonal
SERUM STUDIES
Complete blood count
Electrolytes
Calcium
Phosphate
Uric acid
IMAGING
KUB - 5 typical location of stone impaction : calyx ureteropelvic junction (UPJ) pelvic brim (iliacs) posterior pelvis (broad ligament, females) ureterovesical junction (UPJ)
KUB
Intravenous pyelogram (IVP) - nowadays, rarely used in the acute
setting
Ultrasound - pregnancy & pediatrics : avoids radiation - poor visualization of small renal & ureteral stones
Non-contrast computed tomography - 97% sensitive & 97% specific for stone - 4 signs of obstruction : hydroureter perinephric stranding hydronephrosis nephromegaly
Imaging modalitiesPreference number
Examination LE
1. Non-contrast CT
1
2. Excretory urography (IVP)
Standard Procedure
3.. KUB + USG 2a
ACUTE MANAGEMENTPain control : - narcotics - NSAIDSIV fluidsAB if urinary infection (+)Strain urineRecommended indication for admission : - uncontrolled pain - unremitting nausea/vomiting with inability to tolerate PO - obstructed, infected renal unit - obstructed, solitary renal unit - bilateral obstruction - anuria
Pain relief for patients with acute stone colic
Pharmacological agent
LE
1. Diclofenac sodium
1b
2. IndomethacinIbuprofen
1b
3. Hydromorphine
hydrochloride (+ atropine)MethamizolPentazocine
Tramadol
4
Recommended indication for watchful waiting
- no evidence of infection - pain well-controlled with oral medication - stone < 5 mm - no obstructionSpontaneous stone passage rates based on
location : - proximal : 20% - distal : 70%
Spontaneous passage rates within 1 year : < 4 mm 90% 4 – 6 mm 60% > 6 mm 20%
Obstruksi ureter akut
Peningkatan tekanan pelvis renalis
Nyeri meningkat
prostaglandin
diuresis
Suspresi hormon anti diuretikVaso dilatasi ginjal
Obstruksi ureter akut
Peningkatan tekanan pelvis renalis
Edema perirenal dan periureter
Kerusakan ginjal :terjadi oleh karena iskhemia infark / nekrosis pada duktus koligentes dan
tubulus proksimalis
Dilatasi pelvis renalis
MEDICAL OPTIONS DURING EXPECTANT MANAGEMENTPain controlAB prophylaxisAlpha blockersCa channel blockerssteroids
INDICATIONS FOR ACTIVE STONE REMOVALThe stone diameter is > 7 mm (because of a
low rate of spontaneous passage)Pain relief cannot be achievedStone obstruction associated with infectionPyonephrosis or urosepsisIn single kidneys with obstructionBilateral obstruction
SURGERYESWLUreteroscopyPercutaneous nephrolithotomy (PNL)LaparascopyOpen surgery
SURGERYESWL - imaging : fluoroscopy - anesthesia : sedation or general - potential long-term renal effect : renal injury/scar, hypertension
- complications : hematoma (<1%) UTI/sepsis obstruction injury to organ
- contraindications : pregnancy calcified
aneurysm morbid obesity bleeding diathesis
ESWL : Extra Corporeal Shock Wave Lithotripsy
STONE FREE RATES
proximal distal ureter ureter
<1.0 cmESWL 84% 85%Ureteroscopy 56% 89%PCNL 76% -
≥1.0 cmESWL 72% 74%Ureteroscopy 44% 73%PCNL 74% -