Urolithiasis (urinary stones disease) presentation
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Transcript of Urolithiasis (urinary stones disease) presentation
Urolithiasis
Dr Ahmad KharroubyUrology Specialist
Urolithiasis (from Greek oucircron-urine and lithos-stone) is the condition where urinary stones are formed or located anywhere in the urinary system
Urolithiasis
Background
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
Epidemiology
Urolithiasis occurs in all parts of the world A lifetime risk
2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia
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
Epidemiology
Chemical types and etiology
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Background
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
Epidemiology
Urolithiasis occurs in all parts of the world A lifetime risk
2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia
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
Epidemiology
Chemical types and etiology
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Background
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
Epidemiology
Urolithiasis occurs in all parts of the world A lifetime risk
2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia
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
Epidemiology
Chemical types and etiology
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Epidemiology
Urolithiasis occurs in all parts of the world A lifetime risk
2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia
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
Epidemiology
Chemical types and etiology
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Epidemiology
Urolithiasis occurs in all parts of the world A lifetime risk
2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia
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
Epidemiology
Chemical types and etiology
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Epidemiology
Urolithiasis occurs in all parts of the world A lifetime risk
2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia
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
Epidemiology
Chemical types and etiology
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Epidemiology
Urolithiasis occurs in all parts of the world A lifetime risk
2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia
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
Epidemiology
Chemical types and etiology
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Urolithiasis occurs in all parts of the world A lifetime risk
2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia
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
Epidemiology
Chemical types and etiology
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Epidemiology
Chemical types and etiology
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Chemical types and etiology
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones
Chemical Types
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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Radio-faint
Cystine Stones
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Prognosis
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
80 pass spontaneously 20 require hospital admission or intervention because
of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure
Prognosis
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Prognosis
Recurrence rates after an initial episode of ureterolithiasis
14 at 1 year 35 at 5 years 52 at 10 years
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
History
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
History
The presentation is variable
Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms
If present symptoms are usually moderate and easily controlled
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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Obstructive ureteral stone
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Classic Renal Colic
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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Staghorn stone
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Acute renal failure
Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree
ureteropelvic junction pelvic brim ureterovesical junction
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Ureteral Stone
Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is
present
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Upper ureter
Tends to radiate to the flank and lumbar areas
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute
diverticulitis on the left
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Distal Ureter and UVJ stones
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
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Pain distribution review
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Bladder Stones
Usually asymptomatic and are passed relatively easily during urination
Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Phases of an attack
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 15-3 hours
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Physical exam
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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed
Diagnosis
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Laboratory tests
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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Imaging studies
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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- 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
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Imaging studies
IVP (urography) historically the criterion standard
In rare select situations
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Management
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Emergency Renal Colic
IV access to allow Fluid Analgesics
Paracetamol NSAID Opiod
Antiemetic
In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Approach Considerations
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
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Important
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
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Approach Considerations
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
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Approach Considerations
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
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Approach Considerations
Most patients with acute renal colic can be treated on an ambulatory basis
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Approach Considerations
Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Clinic Follow up
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
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Active medical expulsive therapy
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
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Approach Considerations
An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Emergency Advice
Patients should be told to return for fever uncontrolled pain uncontrolled vomiting
Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention
Approach Considerations
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Approach Considerations
Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure
Such patients require mandatory urology follow up
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Approach Considerations
About 15-20 of patients require invasive intervention eventually as emergency or electively due to
stone size continued obstruction Infection intractable pain
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Indications for Surgery
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
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Surgical options
Obstruction relief Ureteral stent insertion Percutaneous nephrostomy
Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic
pyelo-lithotomy ureterolithotomy cystolithotomy
Open anatrophic nephrolithotomy
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Surgical options
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
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Surgical options
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
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Surgical options
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
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Ureteral Stent
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
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Extracorporeal shockwave lithotripsy
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
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Extracorporeal shockwave lithotripsy
The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an
Electrohydraulic Electromagnetic piezoelectric source
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Ureteroscopy
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
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Ureteroscopy
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 nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Percutaneous nephrostolithotomy
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
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Percutaneous nephrostolithotomy
In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Open Surgery
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 longer convalescence increased requirements for blood
transfusion
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Approach Considerations
Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including
multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Medical Therapy for Stone Disease
Urinary calculi composed predominantly of calcium cannot be dissolved
medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Medical Therapy for Stone Disease
Uric acid and cystine calculi can be dissolved with medical therapy
Suitable option in patients with uric acid stones who do not require urgent surgical intervention
Is based on alkalization of the urine
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Medical Therapy for Stone Disease
Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a high sodium load
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Medical Therapy for Stone Disease
The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Chemoprophylaxis
Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Chemoprophylaxis
Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine
determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Long-Term Monitoring
Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Chemoprophylaxis
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
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Dietary Measures
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
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Dietary Measures
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
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
Thank you
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-
References
bull Main references
bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013
bull Campbell-Walsh Urology 10th edition
bull Smith and Tanaghos General Urology Eighteenth Edition
bull Images used in this presentation are from different web based resources
bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management
- Urolithiasis
- Slide 2
- Background
- Slide 4
- Slide 6
- Slide 7
- Epidemiology
- Slide 9
- Epidemiology (2)
- 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
- Prognosis
- Slide 24
- Prognosis (2)
- History
- History (2)
- 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
- Phases of an attack (2)
- Physical exam
- Slide 44
- Diagnosis
- Slide 46
- Laboratory tests
- Slide 48
- Slide 49
- Imaging studies
- Slide 51
- Slide 52
- Imaging studies
- Management
- Emergency Renal Colic
- Approach Considerations
- Important
- Approach Considerations (2)
- Approach Considerations (3)
- Approach Considerations (4)
- Approach Considerations (5)
- Approach Considerations (6)
- Clinic Follow up
- Active medical expulsive therapy
- Approach Considerations (7)
- Emergency Advice
- Approach Considerations (8)
- Approach Considerations (9)
- Approach Considerations (10)
- Indications for Surgery
- Surgical options
- Surgical options (2)
- Surgical options (3)
- Surgical options (4)
- Ureteral Stent
- Percutaneous nephrostomy
- Extracorporeal shockwave lithotripsy
- Extracorporeal shockwave lithotripsy (2)
- Ureteroscopy
- Ureteroscopy (2)
- Percutaneous nephrostolithotomy
- Percutaneous nephrostolithotomy (2)
- Open Surgery
- Approach Considerations (11)
- Medical Therapy for Stone Disease
- Medical Therapy for Stone Disease (2)
- Medical Therapy for Stone Disease (3)
- Medical Therapy for Stone Disease (4)
- Chemoprophylaxis
- Chemoprophylaxis (2)
- Long-Term Monitoring
- Long-Term Monitoring (2)
- Chemoprophylaxis (3)
- Chemoprophylaxis (4)
- Chemoprophylaxis (5)
- Dietary Measures
- Dietary Measures (2)
- Thank you
- References
-