Dr Zakir Hussain Rajpar Assistant Professor Of UrologyLiaquat University Of Medical And Health Sciences

Urolithiasis (from Greek oucircron-urine and lithos-stone) is the condition where urinary stones are formed or located anywhere in the urinary system

Urolithiasis

Kidney stones Ureteral stones Bladder stones Urethral stones

Urolithiasis

Urolithiasis is a common disease that is estimated to produce medical costs of $21 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

Renal colic affects approximately 12 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

Background

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West Hot Climate Dietary habits Hereditary factors

Epidemiology

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 31

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Urolithiasis (from Greek oucircron-urine and lithos-stone) is the condition where urinary stones are formed or located anywhere in the urinary system

Urolithiasis

Kidney stones Ureteral stones Bladder stones Urethral stones

Urolithiasis

Urolithiasis is a common disease that is estimated to produce medical costs of $21 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

Renal colic affects approximately 12 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

Background

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West Hot Climate Dietary habits Hereditary factors

Epidemiology

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 31

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Kidney stones Ureteral stones Bladder stones Urethral stones

Urolithiasis

Urolithiasis is a common disease that is estimated to produce medical costs of $21 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

Renal colic affects approximately 12 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

Background

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West Hot Climate Dietary habits Hereditary factors

Epidemiology

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 31

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Urolithiasis is a common disease that is estimated to produce medical costs of $21 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

Renal colic affects approximately 12 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

Background

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West Hot Climate Dietary habits Hereditary factors

Epidemiology

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 31

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Renal colic affects approximately 12 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

Background

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West Hot Climate Dietary habits Hereditary factors

Epidemiology

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 31

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West Hot Climate Dietary habits Hereditary factors

Epidemiology

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 31

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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 31

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Calcium Stone

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Radio-faint

Cystine Stones

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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 calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

urinary frequency dysuria

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor 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

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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 longer hospitalization increased requirements for blood

transfusion

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Metabolic evaluation is done by a typical 24-hour urine determination of

urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

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

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References

• UROLITHIASIS
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Slide 10
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• History
• Slide 24
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Slide 39
• Physical exam
• Slide 41
• Diagnosis
• Slide 43
• Laboratory tests
• Slide 45
• Slide 46
• Imaging studies
• Slide 48
• Slide 49
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Slide 55
• Slide 56
• Slide 57
• Clinic Follow up
• Active medical expulsive therapy
• Slide 60
• Slide 61
• Indications for Surgery
• Surgical options
• Slide 64
• Slide 65
• Slide 66
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Slide 70
• Ureteroscopy
• Slide 72
• Percutaneous nephrostolithotomy
• Slide 74
• Open Surgery
• Long-Term Monitoring
• Slide 77
• Chemoprophylaxis
• Slide 79
• Slide 80
• Dietary Measures
• Slide 82
• Thank you
• References