Renal Tract Stones

Angelika Na

Renal tract stonesRenal tract stones

10% of Caucasian men by age 70 Recurrence

10% in 1 year, 50% in 10 year Risk factors

Age 20-50 Male, genetics (RTA, cystinuria) Summer Water intake Diet Occupation

Renal tract stonesRenal tract stones

Composition Calcium oxalate (85% of all renal calculi) HyperCa eg. hyperPTH, Paget’s dx

Uric acid (5-10%) Gout, myeloproliferative disorder

Calcium phosphate + calcium oxalate (10%) RTA

Calcium phosphate (rare) Struvite (infection stones - 2-20%) Cystine (1%)

Cystinuria

Renal tract stonesRenal tract stones

XR Radio-opaque

Calcium phosphate, calcium oxalate

Radiolucent Relative - cystine (sulphur), struvite

Complete - uric acid, triamterene, xanthine, indinavir

Size & shape Staghorn calculi

Kidney stonesKidney stones

Pain, haematuria UTIs (staghorn, struvite) Pyonephrosis, perinephric abscess, septic, pyelonephritis

Flank pain

Kidney stones - MxKidney stones - Mx Watchful waiting

<5 mm (20%), 5-10mm (25%), 11-15 mm (40%), >15 mm (30%) will require intervention

ESWL <1 cm (80%), 1-2 cm (60%), >2 cm (50%) stone free rates.

Flexible ureteroscopy + laser <2 cm (80%), >2 cm (50%); 10% pt require >2tx

PCNL + lithotripsy 80-90% stone free rates.

Open surgery (nephrolithotomy) Medical mx

Ureteric stones - Clinical

Ureteric stones - Clinical

Renal colic - loin to groin Uncomfortable, doubled-up with pain, n&v

Fever - BC, IV fluids + Abx, nephrostomy

Pregnancy test Dipstick + MSU FBE, UEC, Ca, Uric acid

Differential DiagnosisDifferential Diagnosis AAA Pyelonephritis Appendicitis Ovarian pathology Biliary pathology

Ureteric stones - Radiology

Ureteric stones - Radiology

CT KUB XR KUB -? radioopaque (IVP) MR KUB

XR KUBXR KUB

CT KUBCT KUB

Ureteric stones - Mx acute

Ureteric stones - Mx acute

Analgesia - NSAID, opiate Fluid Watchful waiting - stone size <4 mm - 90% pass spontaneously

4-6 mm - 50% >6 mm - 20%

Medical mx - tamsulosin

Ureteric stones - Surgical mx

Ureteric stones - Surgical mx

Indications Pain, bacteriuria, fever, impaired Cr, prolonged unrelieved obstruction, social

Solitary kidney, bilateral stones

Temporary relief of the obstruction Percutaneous nephrostomy JJ stent - SE: bladder irritation

Ureteric stones - Surgical mx

Ureteric stones - Surgical mx

Definitive mx(position of stones) Ureteroscopy ESWL ( JJ stent) PCNL Ureterolithotomy (open, lap) Percutaneous antegrade ureteroscopy

Bladder stonesBladder stones Composition

Struvite (infection), uric acid Age

Men > 50yo, BPH Long term IDC / SPC Children - low phosphate diet

Clinical Asymptomatic (sc patients) - XR, US Haematuria, urgency, UTIs, LUTS

Mx Cystolitholapaxy (endoscopic, open)

Renal tract stonesRenal tract stones

Treat underlying cause- Hyperparathyroidism - parathyroidectomy

- Hyperuricosuria - allopurinol + urine alkalinisation

- Homocysteinuria - D-penicillamine Prevention

Fluid intake Calcium Proteins Wine Oxalate