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latest investigations and management of urolithiasis in 2014. Slides during my seminar of urinary stone.
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Investigations and Management of UrolithiasisAmalina Mohd Daud (0917298)
Outline of Presentation
• Investigations
• Basic Laboratory: Urine and Blood
• Imaging: KUB Xray, Ultrasound, IVU and CTU
• Radionuclide study: DTPA scan
• Management
• Preventions
Urine
• UFEME
• Urine culture
• 24 hour urine collection
Urine
• UFEME
• Red cells (microscopic hematuria)
• White cells (infection)
• Nitrite (infection)
• Approximate pH (N: 5.8-6.2)
• Specific Gravity (hydrational status)
• Urine culture –presence of urea splitting organisms
• Urine microscopy
• 24 hour urine collection –creatinine clearance, volume
- measure Mg, Na, uric acid, oxalate, citrate, phosphate
Cystinuria Struvite calculi Calcium oxalate
Hexagonal crystal Rectangular ‘coffin-lid’ crystal
Tetrahedral envelope crystal
Blood
• FBC (anemia of chronic disease, CKD)
• Renal Profile
• Urea and creatinine
• Uric acid
• Calcium (high investigate further for hyperparathyroidism)
• Sodium
• Potassium (low: suspect distal RTA)
• CRP
• Coagulation Profile (if intervention was planned)
Imaging: Plain KUB X-rays
• Not useful
• Radioluscent stone
• Stone <4mm
• Lies over sacrum/bony structures
• Bowel gas can obscure its efficacy
• Cannot differentiate
• Stones
• Calcified LN
• Phleboliths
• Sensitivity: 50-70%
75% radiopaque
KUB X-ray
Click icon to add picture
Imaging: KUB Ultrasound
• Sensitivity to detect renal calculi ~95% (complement KUBXR)
• Very sensitive to detect obstruction and radioluscent stone
• Non-invasive
• May miss small stone (<5mm) and ureteral stone
• Particularly important in pregnant women
KUB Ultrasound
Click icon to add picture
- Dilated ureteral tunnel
- Stone and shadowing distal to the stone
Imaging: IVU
• Provide anatomical and functional informations
• Size and location of the stone
• Presence and severity of obstructions
• Renal and ureteral abnormalities
Imaging: IVU
Indications
• Urolithiasis/nephrolithiasis
• Suspected urinary tract pathology
• Repeated infections
• Idiopathic hematuria
• Investigate uncontrolled HPT in young adults
• Renal colic
• Trauma
• VUR
Contraindications
• General contraindications to water soluble contrast agents
• Hepatorenal syndrome
• Thyrotoxicosis
• Pregnancy (allow 28 days from childbirth)
• Blood urea raised about 12mmol/L
Preliminary FilmLook for radiopaque stone before contrast injected
Immediate FilmNephrogram
5 minute film-Determine symmetrical excretion
- Determine need for more contrast
15 minute film
Click icon to add picture
Delineate pelvicalyceal junction and ureter
Release / 25 minute filmDemonstrate distended bladder
Post-Micturition Film-demonstrate bladder emptying success
-demonstrate return of dilated upper urinary tract with relief of bladder pressure
Imaging: CT-urography
• Evaluate kidney, ureter and bladder
• Not require any bowel preparations
• Faster than IVU
• Radiation dose higher than IVU
- Use CT protocol for patient under age 40
Imaging: CT-Urography
Indications
• Urinary calculi
• Hematuria
• Flank and abdominal pain
• Renal and urothelial neoplasm
• Congenital anomalies of kidney and ureter
Contraindications
• Renal insufficiency
• Prior severe reaction
• pregnancy
Non-contrast-Evaluate for calculi, fat-containing lesions and parenchymal calcifications
- Stone in middle segment of right ureter
Radionuclide study : DTPA
• Diethylene triamine pentaacetic acid
• Evaluate obstruction, perfusion, GFR quantifications
• Adv: relative split function of both kidney
DTPA
Relative split function
How to Investigate Urolithiasis??
Urine- UFEME- Urine C+S- 24 hour urine
collection
Blood- FBC- Renal Profile
Imaging- KUB X-ray- KUB Ultrasound- IVU
Plan for Intervention- DTPA If IVU contraindicated
- CTU
Management
Initial Management• IV access for fluid, analgesics and antiemetics
• Analgesics: • NSAIDS (Voltaren)
• avoid Morphine – provoke/ prolong ureteric spasm and pain
• Antibiotics : IV cefuroxime 1.5mg TDS if infection
• Imaging
Evidence of Obstruction or Infections?
• Complete obstruction of ureter (IVU, CTU)
• Infection above the obstructing stone
• Aim: prevent renal damage
• Options:
• Percutaneous nephrostomy
• Ureteral stent placement
• Endoscopic removal of stone
Ureteral Stent Placement
• Relieve obstruction and infection of ureter
• Primary choice due to less invasiveness and less bleeding risk
• Allow urine drainage and improve renal colic
• Cx: blocked, kinked, dislodged and infected
Percutaneous Nephrostomy Tube• Choice of treatment if stent cannot be placed percutaneously or require
future percutaneous treatment of stone burden
• Temporary urinary diversion
• Contraindicated:
• Bleeding diasthesis
• Uncooperative patient
• Severe hyperkalemia (>7mEq/L)
• Complications
• Bleeding
• Sepsis
• Injury to other organs
Endoscopic Removal of Stone
No evidence of obstruction or infectionObservation Surgical
- stone <5mm
- Asymptomatic patients
• persistent, recurrent or severe pain
• Obstruction or infection
• Risk of pyonephrosis and urosepsis
• Solitary kidney
• Bilateral obstruction
No evidence of Obstruction or InfectionLocation <5mm 5-10mm 1-2cm >2cm
Urethra Pass spontaneously
Open Vesicolithotripsy
Bladder Pass spontaneously
Transurethral Cystolitholapaxy
Ureter MET URSESWLMET
URSESWL
URSOpen/ Laparoscopic uretherolithotomy
Kidney MET ESWLRIRSMET
ESWLRIRS
PCNL
# At any size, chemolysis is important
ChemolysisStone Chemolysis
Calcium -least amenable of stone- Strong acid for stone to dissolve (not safe for human)
Struvite stone - Soluble in acid condition- Rx: Acetohydroxamic acid (AHA) 250 mg TDS (irreversible
urease inhibitor)- AE: hemolytic anemia, neurosensory deficit and
thrombophlebitis
Uric acid stone -soluble in alkaline condition- Rx: Na bicarbonate 650mg-1g TDS/QID (urine alkalinization) Acetazolamide 250-500mg ON (carbonic anhydrase inhibitor)
Cystine stone -soluble in alkaline condition-Rx: (D-penicillamine 1-2mg/d OR a-mercaptopropionylglycine OR acetylcysteine ) + Na bicarbonate
MET
• Nephrolithiasis: 3-8 mm
• Likelihood of 65% for stone passage
• Conservative management: oral/iV hydration + analgesics, + medications that promote stone passage
• Rx: Tamsulosin (a-blocker), Nifedipine
• Relaxes the intramural smooth muscle of ureter urine and stone passage
• Controversial: safety?? – use as off label
Bladder stone
• Options
• Transurethral cystolitholapaxy
• Percutaneous suprapubic cystolitholapaxy (paeds)
• Method
• Cystoscope fragment stone stone remove via cystoscope
Extracorporeal Shockwave Lithotripsy (ESWL)
• Underwater energy wave shatter stone into passable fragments
• Fragments pass down through ureter ureteric colic (diclofenac)
• Indications
• stone <2cm
• Upper and middle ureter; kidney
• Contraindications
• Pregnant mother
• Untreatable bleeding diasthesis
• Impacted stone
• Ureteral obstruction distal to the stone
• Complications
• Ureteric obstructions (bulky fragments) ureteral stent prior to ESWL
• Urosepsis prophylactic antibiotic prior to ESWL (currently not needed)
Uteroscopic Lithotripsy (URS)
• Endoscopic: pass ureteroscope fragment stone stone pass / wire basket to fish out stone
• Advantage: remove hard stone, ureteral dilatation
• Can be performed in patient with bleeding diasthesis
• Contraindications: untreated UTI
• Complications (rare)
• Hematuria
• Ureter perforation
• Stone migration
• First choice for ureteral stone >10mm• First choice for distal ureteral stone
<10mm other than ESWL
Open/ Laparoscopic Urolithotomy
• Indications
• Complex stone burden : multiple, impacted ureteric stone
• Treatment failure
• Morbid obesity
• Skeletal abnormalities
• Plan for partial nephrectomy and nephrectomy
• Patient’s choice
• Stone in ectopic kidney
Retrograde Intrarenal Surgery (RIRS)
• Indications
• Failed ESWL
• Lower calyx stone
• Concomittant ureteric and kidney stone
• Bleeding disorders, unfit for anesthesia
• Gross obesity
• Need for complete stone removal . Eg: pilot
• Complications: rare
• Guide wire pass and ureteral dilate flexible ureteronoscope irrigate lithotripsy stone retrieve with basket ureteral stent placement
Percutaneous Nephrostolithotomy (PCNL)• Indications
• Renal stone >2cm
• Staghorn calculi
• Failed / contraindicated for ESWL
• Contraindications
• Uncorrected bleeding diasthesis
• Untreated UTI
• Complications
• Perforation of collecting systems
• Perforation of colon or pleural cavity
• Hemorrhage from punctured renal parenchyma
Placement of hollow needle into collecting system
fragmented remove stone/ allow drainage
Prevention
Preventions
Thank you =)