Urolithiasis
Dr. Ahmad Kharrouby
Urology Specialist
Urolithiasis (from Greek oûron-urine and lithos-stone) is
the condition where urinary stones are formed or located
anywhe...
Background
 Kidney stones
 Ureteral stones
 Bladder stones
 Urethral stones
Urolithiasis
 Urolithiasis is a common
disease that is estimated to
produce medical costs of $2.1
billion per year in the United
State...
 Renal colic affects approximately 1.2 million people
each year in USA and accounts for approximately 1% of
all hospital ...
Epidemiology
 Urolithiasis occurs in all parts of the world
 A lifetime risk:
 2-5% for Asia
 8-15% for the West
 20% for the King...
 The lower the economic status, the lower the likelihood
of renal stones
 Most at 20-49 years
 Peak incidence at 35-45 ...
Chemical types and etiology
 Four main chemical types:
 Calcium stones
 Struvite (magnesium ammonium phosphate) stones
 Uric acid stones
 Cystine...
 Calcium stones
account for 75%
of Urolithiasis.
 Radio-opaque
 Multiple factors
and etiologies
 Mostly incidental
Cal...
 Incidental
 Hyperparathyroidism
 Increased gut absorption of calcium
 Renal calcium leak
 Renal phosphate leak
 Hpe...
Calcium Stone
 Account for 15% of renal calculi
 Infectous stones
 Gram-negative rods capable of
splitting urea into ammonium, which
...
 Stag horn stones
are non
obstructive thus
painless
 Slowly growing
 Discovered
incidentally
Struvite (magnesium ammoni...
 Account for 6% of renal
calculi
 Urine pH less than 5.5
 High purine intake eg.
 organ meats
 legumes
 malignancy
...
Uric Acid Stones
Uric Acid Stones
 2% of renal calculi
 Autosomal recessive trait
 Intrinsic metabolic defect resulting in
failure of renal tubular reabs...
 Radio-faint
Cystine Stones
Prognosis
 80 % pass spontaneously
 20% require hospital admission or intervention because
of:
 unrelenting pain
 inability to r...
Prognosis
 Recurrence rates after an initial episode of
ureterolithiasis:
 14% at 1 year
 35% at 5 years
 52% at 10 ye...
History
History
The presentation is variable.
 Patients with urinary calculi may report
 Pain
 Infection
 Hematuria
 Asymptom...
Silent Kidney stones
 Small nonobstructing stones in
the kidneys only occasionally
cause symptoms.
 If present, symptoms...
 The passage of stones into
the ureter is associated with
classic renal colic because
of:
 subsequent acute obstruction
...
Classic Renal Colic
 Acute onset of severe flank pain radiating to the groin
 Gross or microscopic hematuria
 Nausea, a...
 Staghorn calculi are often
relatively asymptomatic.
 Branched kidney stone occupying
the renal pelvis and at least one
...
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:
 ureterop...
UPJ Stone
 Stones obstructing the
ureteropelvic junction may
present with mild-to-severe
deep flank pain without
radiatio...
Ureteral Stone
 Cause abrupt, severe, colicky pain in the flank and
ipsilateral lower abdomen
 with radiation to the tes...
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
diver...
Distal Ureter and UVJ stones
 Cause pain that tends to radiate into the groin or testicle
in the male or labia majora in ...
Pain distribution review
Bladder Stones
 Usually asymptomatic and are passed relatively easily
during urination.
 Rarely, a patient reports posit...
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...
Physical exam
 Dramatic costovertebral angle
tenderness
 unremarkable abdominal evaluation
 painful testicles but normal-appearing
 ...
Diagnosis
 The diagnosis of nephrolithiasis is often made on the
basis of clinical symptoms alone, although confirmatory
tests are ...
Laboratory tests
 The recommended based on EUA recommendations:
 Urinary sediment/dipstick test: To demonstrate blood cells
 Serum creat...
 May be helpful:
 CBC in febrile patients
 Serum electrolyte assessment in vomiting patients
 24-Hour urine profile on...
Imaging studies
 Noncontrast abdominopelvic CT scan: The imaging
modality of choice for assessment of urinary tract
disease, especially a...
 Renal ultrasonography:
 Renal stone
 Hydronephrosis or ureteral dilation
 Misses 30 % of stones
 Plain abdominal rad...
Imaging studies
 IVP (urography) historically, the criterion standard
 In rare select situations:
 Plain renal tomograp...
Management
Emergency Renal Colic
 IV access to allow :
 Fluid
 Analgesics:
 Paracetamol
 NSAID
 Opiod
 Antiemetic
 In case of...
Approach Considerations
 In emergency settings what should be kept in mind is the
small percentage suffering renal damage...
Important
 The most morbid and potentially dangerous aspect of
stone disease is the combination of urinary tract
obstruct...
Approach Considerations
 The size of the stone is an
important predictor of
spontaneous passage.
 A stone less than 4 mm...
Approach Considerations
 Hospital admission is clearly necessary when any of the
following is present:
 Oral analgesics ...
Approach Considerations
 Relative indications to consider for a possible admission
include comorbid conditions
 diabetes...
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 an...
Clinic Follow up
 Patients who do not meet admission criteria to be
discharged on medical expulsive therapy from the ED i...
Active medical expulsive therapy
 Paracetamol PRN for pain with or without Codeine
 NSAID PRN for pain
 Oral opiod anal...
Approach Considerations
 An important aspect of medical and preventive therapy is
maintaining a good fluid intake and sub...
Emergency Advice
 Patients should be told to return for :
 fever
 uncontrolled pain
 uncontrolled vomiting
 Patients ...
 General recommendation not to wait longer than 4
weeks for a stone to pass spontaneously before
considering intervention...
Approach Considerations
 Larger stones (ie, ≥ 7 mm) that are unlikely to pass
spontaneously require some type of surgical...
Approach Considerations
 About 15-20% of patients require invasive intervention
eventually as emergency or electively due...
Indications for Surgery
 The primary indications for surgical treatment include:
 Pain
 Infection
 Obstruction
 Indic...
Surgical options
 Obstruction relief:
 Ureteral stent insertion
 Percutaneous nephrostomy
 Definitive surgical treatme...
Surgical options
 For an obstructed and infected collecting system
secondary to stone disease
 Emergency surgical relief...
Surgical options
 The vast majority of symptomatic urinary tract calculi are
now treated with noninvasive or minimally in...
Surgical options
 ESWL and ureteroscopy are internationaly recognized as
first-line treatments for ureteral stones.
 The...
Ureteral Stent
 Guarantees drainage of urine from
the kidney into the bladder and
bypass any obstruction.
 Relieves rena...
Percutaneous nephrostomy
 Indicated if stent placement is
inadvisable or impossible.
 In particular patients with
pyonep...
Extracorporeal shockwave
lithotripsy
 ESWL, the least invasive of the
surgical methods of stone
removal
 Utilizes an und...
Extracorporeal shockwave lithotripsy
 The patient, under varying degrees of anesthesia
 The shock head delivers shockwav...
Ureteroscopy
 Ureteroscopic manipulation of a
stone is a commonly applied
method of stone removal
 A small endoscope, wh...
Ureteroscopy
 Flexible ureteroscopy allows tackling
of even lower calyceal stones
 Stones are fragmented using
 Swiss l...
Percutaneous nephrostolithotomy
 Percutaneous procedures are generally reserved for
large and/or complex renal stones and...
Percutaneous nephrostolithotomy
 In some cases, a combination
of SWL and a percutaneous
technique is necessary to
complet...
Open Surgery
 Open surgery has been used less
and less often since the
development of the previously
mentioned techniques...
Approach Considerations
 Metabolic evaluation and treatment at clinic are indicated
for patients at greater risk for recu...
Medical Therapy for Stone Disease
 Urinary calculi composed predominantly of calcium
cannot be dissolved
 medical therap...
Medical Therapy for Stone Disease
 Uric acid and cystine calculi can be dissolved with
medical therapy.
 Suitable option...
Medical Therapy for Stone Disease
 Sodium bicarbonate can be used as the alkalizing agent
 But potassium citrate is usua...
Medical Therapy for Stone Disease
 The dosage of the alkalizing agent should be adjusted to
maintain the urinary pH betwe...
Chemoprophylaxis
 Prophylactic therapy might include:
 most importantly, augmentation of fluid intake.
 limitation of d...
Chemoprophylaxis
Better to base medical therapy for long-term
chemoprophylaxis of urinary calculi on the results of a
24-h...
Long-Term Monitoring
 Metabolic evaluation is done by a typical 24-hour urine
determination of:
 urinary volume
 pH
 s...
Long-Term Monitoring
 Most common findings are
 Hypercalciuria
 Hyperuricosuria
 Hyperoxaluria
 Hypocitraturia
 low ...
Chemoprophylaxis
 Chemoprophylaxis of uric acid and cystine calculi
consists primarily of long-term alkalinization of uri...
Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in
patients with pure uric acid stones, allopurinol (30...
Chemoprophylaxis
 Pharmaceuticals that can bind free cystine in the urine:
 D-penicillamine
 2-alpha-mercaptopropionyl-...
Dietary Measures
 In almost all patients in whom stones form, an increase in
fluid intake and, therefore, an increase in ...
Dietary Measures
 The only other general dietary guidelines are to avoid
excessive salt and protein intake.
 Moderation ...
Thank you
References
• Main references:
• Medscape article nephrolithiasis by J Stuart Wolf Jr, MD, FACS updated
feb 11, 2013
• Camp...
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Urolithiasis (urinary stones disease) presentation

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Urolithiasis (urinary stones disease) presentation

  1. 1. Urolithiasis Dr. Ahmad Kharrouby Urology Specialist
  2. 2. Urolithiasis (from Greek oûron-urine and lithos-stone) is the condition where urinary stones are formed or located anywhere in the urinary system. Urolithiasis
  3. 3. Background
  4. 4.  Kidney stones  Ureteral stones  Bladder stones  Urethral stones Urolithiasis
  5. 5.  Urolithiasis is a common disease that is estimated to produce medical costs of $2.1 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
  6. 6.  Renal colic affects approximately 1.2 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
  7. 7. Epidemiology
  8. 8.  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
  9. 9.  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 3:1 Epidemiology
  10. 10. Chemical types and etiology
  11. 11.  Four main chemical types:  Calcium stones  Struvite (magnesium ammonium phosphate) stones  Uric acid stones  Cystine stones Chemical Types
  12. 12.  Calcium stones account for 75% of Urolithiasis.  Radio-opaque  Multiple factors and etiologies  Mostly incidental Calcium stones
  13. 13.  Incidental  Hyperparathyroidism  Increased gut absorption of calcium  Renal calcium leak  Renal phosphate leak  Hperuricosuria  Hperoxaluria  Hypocitraturia  Hypomagnesuria Calcium Stone Known etiologies
  14. 14. Calcium Stone
  15. 15.  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
  16. 16.  Stag horn stones are non obstructive thus painless  Slowly growing  Discovered incidentally Struvite (magnesium ammonium phosphate) stones
  17. 17.  Account for 6% of renal calculi  Urine pH less than 5.5  High purine intake eg.  organ meats  legumes  malignancy  25% of patients have gout Uric acid stones
  18. 18. Uric Acid Stones
  19. 19. Uric Acid Stones
  20. 20.  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
  21. 21.  Radio-faint Cystine Stones
  22. 22. Prognosis
  23. 23.  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
  24. 24. Prognosis  Recurrence rates after an initial episode of ureterolithiasis:  14% at 1 year  35% at 5 years  52% at 10 years
  25. 25. History
  26. 26. History The presentation is variable.  Patients with urinary calculi may report  Pain  Infection  Hematuria  Asymptomatic
  27. 27. Silent Kidney stones  Small nonobstructing stones in the kidneys only occasionally cause symptoms.  If present, symptoms are usually moderate and easily controlled.
  28. 28.  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
  29. 29. 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%
  30. 30.  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
  31. 31. Acute renal failure  Asymptomatic bilateral obstruction  Solitary Kidney with obstructive stone
  32. 32. Location and characteristics of pain from ureteral stones  Depends on the level of obstruction and its degree:  ureteropelvic junction  pelvic brim  ureterovesical junction
  33. 33. UPJ Stone  Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
  34. 34. 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.
  35. 35. Upper ureter  Tends to radiate to the flank and lumbar areas
  36. 36. Mid Ureter  Cause pain that radiates anteriorly and caudally.  Can easily mimic appendicitis on the right or acute diverticulitis on the left.
  37. 37. 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
  38. 38. Pain distribution review
  39. 39. 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).
  40. 40. Phases of an attack
  41. 41. 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 1.5-3 hours
  42. 42. Physical exam
  43. 43.  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
  44. 44. Diagnosis
  45. 45.  The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone, although confirmatory tests are usually performed. Diagnosis
  46. 46. Laboratory tests
  47. 47.  The recommended based on EUA recommendations:  Urinary sediment/dipstick test: To demonstrate blood cells  Serum creatinine level: To measure renal function Labarotary Testing
  48. 48.  May be helpful:  CBC in febrile patients  Serum electrolyte assessment in vomiting patients  24-Hour urine profile on outpatient basis Additional Lab Tests
  49. 49. Imaging studies
  50. 50.  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
  51. 51.  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
  52. 52. Imaging studies  IVP (urography) historically, the criterion standard  In rare select situations:  Plain renal tomography  Retrograde pyelography  Nuclear renal scanning
  53. 53. Management
  54. 54. Emergency Renal Colic  IV access to allow :  Fluid  Analgesics:  Paracetamol  NSAID  Opiod  Antiemetic  In case of infection:  Urine culture  Blood culture accordingly e.g. febrile  Antibiotics
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. Approach Considerations  Hospital admission is clearly necessary when any of the following is present:  Oral analgesics are insufficient to manage the pain.  Intractable vommiting  Ureteral obstruction from a stone occurs in a solitary or transplanted kidney.  Bilateral ureteral obstruction  Ureteral obstruction from a stone occurs in the presence of  a urinary tract infection (UTI)  Fever  Sepsis  Pyonephrosis
  59. 59. Approach Considerations  Relative indications to consider for a possible admission include comorbid conditions  diabetes  dehydration  renal failure  immunocompromised state  perinephric urine extravasation  pregnancy
  60. 60. Approach Considerations Most patients with acute renal colic can be treated on an ambulatory basis.
  61. 61. Approach Considerations  Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
  62. 62. 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.
  63. 63. 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 and/or 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.
  64. 64. Approach Considerations  An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume.
  65. 65. 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
  66. 66.  General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention. Approach Considerations
  67. 67. Approach Considerations  Larger stones (ie, ≥ 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure.  Such patients require mandatory urology follow up
  68. 68. Approach Considerations  About 15-20% of patients require invasive intervention eventually as emergency or electively due to:  stone size  continued obstruction  Infection  intractable pain
  69. 69. 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
  70. 70. 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
  71. 71. 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
  72. 72. 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
  73. 73. 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
  74. 74. 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.
  75. 75. 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
  76. 76. 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
  77. 77. Extracorporeal shockwave lithotripsy  The patient, under varying degrees of anesthesia  The shock head delivers shockwaves developed from an  Electrohydraulic  Electromagnetic  piezoelectric source
  78. 78. 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
  79. 79. 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
  80. 80. Percutaneous nephrostolithotomy  Percutaneous procedures are generally reserved for large and/or complex renal stones and failures from the other 2 modalities  Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter
  81. 81. Percutaneous nephrostolithotomy  In some cases, a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney.
  82. 82. 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.
  83. 83. 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
  84. 84. 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
  85. 85. 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.
  86. 86. 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
  87. 87. Medical Therapy for Stone Disease  The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 6.5 and 7.0.
  88. 88. 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
  89. 89. Chemoprophylaxis Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
  90. 90. 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.
  91. 91. Long-Term Monitoring  Most common findings are  Hypercalciuria  Hyperuricosuria  Hyperoxaluria  Hypocitraturia  low urinary volume
  92. 92. Chemoprophylaxis  Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine.
  93. 93. Chemoprophylaxis If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones, allopurinol (300 mg qd) is recommended
  94. 94. 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
  95. 95. 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.
  96. 96. 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.
  97. 97. Thank you
  98. 98. References • Main references: • Medscape article nephrolithiasis by J Stuart Wolf Jr, MD, FACS updated feb 11, 2013 • Campbell-Walsh Urology 10th edition • Smith and Tanagho's General Urology, Eighteenth Edition • Images used in this presentation are from different web based resources • N.B. The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management.

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