Dr.B.Balagobi: Lecturer Department of Surgery Faculty of Medicine, UOJ
Dr.B.Balagobi: Lecturer Department of Surgery Faculty of Medicine, UOJ
Dr.B.Balagobi: Lecturer Department of Surgery Faculty of Medicine, UOJ
BALAGOBI
Lecturer Department of Surgery Faculty of Medicine,UOJ
Urology
Introduction Aetiopathogenesis How do they present How to asses a patient with stone disease Stone related emergencies Treatment options
Urolithiasis is the presence of one or more calculi at any location of the urinary tract. Incidence is 1-5% of the population Peak age group 20-50 years of age Men affected 3times more 90%of the stones are radio opaque Predominantly a tropical disease Recurrent course unless cause treated
magnesium, pyrophosphate)
tissue,Tumor,Infection,stones
Idiopathic
1. Calcium oxalate (75%) 2. Magnesium Calcium ammonium phosphate stones (15%) 3.Uric acid (6%)
Purine metabolism high turnover of protein metabolism( in Gout, Leukemias & Lymphomas ) They are not visible on X-rays
4.Cystine (2%)
Most common (75%) Due to Renal hypercalciuria Causes= Hyperparathyroidism, Bone Mets, Ca++ absorption Often dark brown(altered blood on surface) Sharp projections+ Radio opaque Even small stonessymptoms.
Calcium
oxalate dihydrates
Also called Triple phosphate Associated with infections by urea splitting bacteria (Proteus) Alkaline Urine Stag-horn calculi typically large takes on shape of calyx Radio opaque Asymptomatic for a long timelate presentation(even CRF)
Idiopathic Dietary factors(low fluid intake,high protein diet,high purine,oxalate) Hyper uricuria(gout,chemotherapy for leukaemia)
Urinary stasis(PUJO,Stricture,Horse shoe kidney(reflux+),BOO
Chronic infection(urease producing organisms:proteustripple phosphate stone. Prolonged immobility (spinal injury,paraplegia)
Most common presenting symptom due to obstruction Ureteric stone:Ureteric colic(loin to groin/scrotumlabia majora/tip of the penis.) and Nausea+,vomiting+,sweating Renal stoneLoin pain bladder stoneLUTS(frequency,urgency,dysuria), supra pubic pain
Painful usually microscopic. RBC in urine is Present in 85-90% of patient with stone
Infection
CRF Stag horn/bladder calclichronic inflammation squamous cell ca Xantho granulomatous pyelonephritis :
end stage of chronic inflammation is difficult,can be mistaken as renal tumour on imaging) Rx:nephrectomy
Clinical assessment is important Always consider a differential diagnosis Objectives of assessment 1. Confirm diagnosis 2. Exclude complications(sepsis,renal failure) 3. Locate size and size of stone(s) 4. Plan therapy
Non urological
Appendicitis Diverticulitis Ectopic pregnancy,salphingitis,tortion of ovarian cyst RupturedAAA biliary colic Pyelonephritis Stricture,tumour,renal infarction Testicular tortion
Urological
To find aetiology
S/Ca,S/uric acid.
S/cr,S/E,FBC Imaging
High risk patients Children Bilateral stones Recurrent stones Known anatomic or biochemical anomaly Large stones Single kidney Strong family history
100mg diclofenac sodium suppository/IM pethidine 75mg with antiemetic (usually 1 or 2 doses enough)
<4mm 80%pass spontaneously 4-6mm 50%pass spontaneously >6mm only 10%pass spontaneously
Absolute indication
Urosepsis renal function intractable pain large stone failure to progression occupation(pilots)
Relative indications:
Small stones(<4-5 mm) More distal the better Pain controlled Absence of renal failure and sepsis Diclofenac sodium Alpha blockers Review and ensure stone has passed Absence of pain does not confirm stone expulsion
Esp @renal pelvis,upper ureter stone non-invasive &no need of anaesthesia may need multiple treatment energy source:Electro hydraulic,Electro magnetic,piezo electric Contraindication:
Complications of ECSWL
Advantages Non invasive Up to 2 cm renal stones Out patient procedure Limitations Lower pole stones Larger stones Hard stones
lithotripsy
Symptomatic Staghorn
Asymptomatic
Young, fit
< 3 cm
ESWL
> 3 cm
PCNL + ESWL No function Nephrectomy
Elderly, unfit
Functioning Observe PCNL + ESWL
Infected
Sterile
Urgent Treatment
Early Treatment
> 5mm
< 5mm
Expectant
URS = Ureteroscopy
Very large
Open suprapubic Transurethral cystolithotomy
lithotrite
Small / Moderate
litholapaxy
- Optical lithtrite - Electrohydraulic - Holmium laser - Ultrasound probe
Treat cause if any Plenty of water Modest diet Limit red meats, alcohol Avoid Calcium supplements Avoid excess salt,milk products, small fish Optimize co morbidities Periodic surveillance tests
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Renal calculi Usually presents in the 40s Are usually due to hyper parathyroidism May be caused by enterobacteria Can be treated with ECSWL Can be treated with percutaneous nephron lithotomy
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Bladder calculi Usually arise from calculi passed down the ureter Occur in bladder diverticula May lead to transitional cell carcinoma of the bladder Can be removed endoscopically May be totally asymptomatic
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Regarding ureteric calculi Usually leads to microscopic haematuria Usually radio lucent All need surgical extraction Are most often composed of calcium oxalate Only 10% of stones<5mm pass spontaneously
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Regarding ureteric calculi An obstructed ureter with infection is a surgical emergency Uric acid stones are radio opaque Calcium oxalate stones have sharp spicules Ammonium magnesium calcium phosphate forms the stag horn calculi Cysteine stones are radio opaque
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Acceptable treatment options of 1cm symptomatic stone@renal pelvis in 40 yr old man Conservative management Diuretic challenge ECSWL PCNL is the first line treatment Dormia basket extraction
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Extra corporeal shock wave lithotripsy(ECSWL) Is the treatment of choice for large stag horn calculi Should not be used for cystine stones It may be complicated by sepsis It is used to treat stones in lower 1./3 of ureter commonly Can be used in obstructed kidney
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