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Nephrolithiasis Pediatric GU Review UCSD Pediatric Urology George Chiang MD Sara Marietti MD Outlined from  The Kelalis-Ki...
Classification  <ul><li>Enzyme Disorders </li></ul><ul><ul><li>Primary Hyperoxaluria </li></ul></ul><ul><ul><ul><li>Type I...
Classification <ul><li>Renal tubular syndromes </li></ul><ul><ul><li>Cystinuria </li></ul></ul><ul><ul><li>Renal tubular a...
Classification <ul><li>Uric Acid Lithiasis </li></ul><ul><li>Enteric urolithiasis </li></ul><ul><li>Idiopathic calcium oxa...
Classification <ul><li>Endemic bladder stone formation </li></ul><ul><li>Secondary urolithiasis </li></ul><ul><ul><li>Infe...
Metabolic Classification Calcium Stones Non-Calcium Hypercalciuria -Absorptive -Renal -Resorptive Uric Acid Hyperuricosuri...
Pathophysiology <ul><li>Formation of stone </li></ul><ul><ul><li>Urinary volume </li></ul></ul><ul><ul><li>pH </li></ul></...
Pathophysiology Saturation Crystal growth and aggregation Supersaturation Crystal Retention Stone formation Nucleation
Presentation <ul><li>Renal colic occurs in 40-75% of children </li></ul><ul><li>Hematuria in 33-90% of children </li></ul>...
Presentation <ul><li>Factors </li></ul><ul><ul><li>Size of stone </li></ul></ul><ul><ul><li>Location of stone </li></ul></...
Presentation <ul><li>H and P </li></ul><ul><ul><li>Prematurity (lasix, formulas) </li></ul></ul><ul><ul><li>Medications  <...
Imaging Radiopaque OR Radiolucent Calcium Oxalate Uric Acid Calcium phosphate Trimaterene Struvite Cystine Silica  Xanthine
Laboratory Evaluation <ul><li>UA C&S </li></ul><ul><li>Serum electrolytes, BUN, and Cr </li></ul><ul><li>CBC </li></ul><ul...
Metabolic Classification Calcium Stones Non-Calcium Hypercalciuria -Absorptive -Renal -Resorptive Uric Acid Hyperuricosuri...
Hypercalciuria <ul><li>Absorptive </li></ul>GI ABSORPTION PLASMA CA PTH URINARY CA
Absorptive Hypercalciuria <ul><li>Type I (Diet Independent) </li></ul><ul><ul><li>High urinary calcium despite diet </li><...
Hypercalciuria <ul><li>Renal Leak </li></ul>Urinary Calcium PTH GI Absorption Bone Resoprtion Plasma Calcium
Hypercalciuria <ul><li>Resorptive (PTH) </li></ul>PTH Urinary Ca Bone Resorption GI Absorption Plasma Ca
Hypercalciuria Intestinal Absorption Fasting Urinary Ca PTH Serum Ca Resorptive Renal Absorptive High High High High High ...
Hyperuricosuria <ul><li>Diet high in purines </li></ul><ul><li>Renal tubular defects </li></ul><ul><ul><li>Defect in renal...
Primary Hyperoxaluria <ul><li>Inherited disorder of glyoxylate metabolism </li></ul><ul><ul><li>Type I: Alanine-glyoxylate...
Primary Hyperoxaluria <ul><ul><li>ESRD </li></ul></ul><ul><ul><ul><li>50% of patients by age 15 and 80% by age 30 </li></u...
Enteric Hyperoxaluria Bowel Disorder Fat malabsorption Excess fats bind to intestinal Ca Insufficient calcium to bind oxal...
Hypocitraturia <ul><li>Citrate is potent stone inhibitor </li></ul><ul><li>Caused by </li></ul><ul><ul><li>acidosis (RTA) ...
RTA <ul><li>Type I  </li></ul><ul><ul><li>Defect in distal tubule to excrete acid </li></ul></ul><ul><ul><li>Dx with syste...
Type I RTA <ul><li>May be a secondary manifestation </li></ul><ul><ul><li>Sjogren’s, Wilson’s, PBC, Jejunoileal bypass </l...
Calcium Stones Misc <ul><li>Immobilization of children is most common cause of secondary hypercalciuria </li></ul><ul><li>...
Metabolic Classification Calcium Stones Non-Calcium Hypercalciuria -Absorptive -Renal -Resorptive Uric Acid Hyperuricosuri...
Uric Acid Lithiasis <ul><li>5% of calculi in pediatric patients </li></ul><ul><li>Orange (can be mistaken for blood) </li>...
Uric Acid Lithiasis <ul><li>Increased intake </li></ul><ul><ul><li>Uricosuric drugs (probenecid, salicylate) </li></ul></u...
Cystinuria <ul><li>Autosomal recessive disorder </li></ul><ul><li>1 in 15,000 live births </li></ul><ul><li>1-3% of childr...
Xanthinuria <ul><li>Enzymatic deficiency of xanthine dehydrogenase </li></ul><ul><ul><li>Urolithiasis, arthropathy, myopat...
Xanthinuria <ul><li>Enzymatic deficiency of xanthine dehydrogenase </li></ul><ul><ul><li>Urolithiasis, arthropathy, myopat...
Infection Stones <ul><li>2-3% of stones in pediatric population </li></ul><ul><li>Urinary pH >6.8 (urease) </li></ul><ul><...
Misc Stones <ul><li>Triamterene stones </li></ul><ul><li>Sulfadiazine stones </li></ul><ul><li>Indinavir stones  </li></ul>
Dietary Recommendations <ul><li>Maintain urine output >2 L/day or >20 cc/kg/day </li></ul><ul><li>No added salt </li></ul>...
 
Pediatric GU Review II Endourology for stone disease
Etiology/Epidemiology <ul><li>1 in 1000 to 1 in 7600 pediatric admissions </li></ul><ul><li>Spontaneous passage rate of 66...
Etiology/Epidemiology <ul><li>Common urine abnormalities: </li></ul><ul><ul><li>Hypercalciuria </li></ul></ul><ul><ul><li>...
Treatment Options <ul><li>ESWL </li></ul><ul><ul><li>Up to 75-98% stone free rates at 3 months with stones up to 2.5 cm </...
Treatment Options <ul><li>ESWL relative contraindications </li></ul><ul><ul><li>Morbid obesity </li></ul></ul><ul><ul><li>...
Treatment Options <ul><li>Ureteroscopy </li></ul><ul><ul><li>First reported in 1929 by Young </li></ul></ul><ul><ul><li>2 ...
Treatment Options <ul><li>Ureteroscopy: Instruments </li></ul><ul><ul><li>Stone retrieval devices can vary </li></ul></ul>...
Treatment Options <ul><li>Intracorporeal lithotripsy </li></ul><ul><ul><li>Ultrasonic lithotripsy (1953) </li></ul></ul><u...
Treatment Options <ul><li>Ureteroscopy technique </li></ul><ul><ul><li>Dilation required in up to 30% </li></ul></ul><ul><...
Treatment Options <ul><li>Percutaneous Endourology </li></ul><ul><ul><li>11 Fr and 15 Fr peel away sheaths have been used ...
Treatment Strategies <ul><li>Renal Calculi </li></ul><ul><ul><li>ESWL for stones <1 cm </li></ul></ul><ul><ul><ul><li>Cont...
Treatment Strategies <ul><li>Renal Calculi </li></ul><ul><ul><li>Percutaneous approach </li></ul></ul><ul><ul><ul><li>Intr...
Treatment Strategies <ul><li>Ureteral calculi </li></ul><ul><ul><li>ESWL effective 54-100% </li></ul></ul><ul><ul><li>Uret...
Treatment Strategies <ul><li>Bladder Calculi </li></ul><ul><ul><li>Open cystolithotomy </li></ul></ul><ul><ul><li>Cystolit...
Question #1 <ul><li>What are the 5 most important chemical abnormalities in stone formers? </li></ul>Low urinary volume Hy...
Question #2 <ul><li>What is the strongest chemical promoter of stone production? </li></ul>Oxalate
Question #3 <ul><li>What are the three types of hypercalciuria? </li></ul>Resorptive  Renal Absorptive
Question #4 <ul><li>What is the medication of choice for renal hypercalciuria? </li></ul>Thiazide diuretics augment calciu...
Question #5 <ul><li>The stones least suitable for ESWL are: </li></ul><ul><li>Calcium oxalate dehydrate </li></ul><ul><li>...
Question #6 <ul><li>The ideal treatment for large staghorn calculi >2.5 cm is: </li></ul><ul><li>ESWL  </li></ul><ul><li>M...
Question #6 <ul><li>The factors predicting stone clearance after ESWL for lower pole stones include all except: </li></ul>...
Question #7 <ul><li>The best treatment for a 2 cm renal stone with a UPJO </li></ul><ul><li>Open pyelolithotomy </li></ul>...
Question #7 <ul><li>The mechanism of stone fragmentation during ESWL include all the following except </li></ul><ul><li>Co...
Question #8 <ul><li>What is the most common renal structural abnormality identified in patients with calcium containing st...
Question #9 <ul><li>Adverse reactions to D-penicllamine include </li></ul><ul><li>Constipation </li></ul><ul><li>Diarrhea ...
Question #10 <ul><li>Urease-producing bacteria hydrolyze urea to which of the following? </li></ul><ul><li>Uric acid </li>...
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Pedi gu review nephrolithiasis

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  1. 1. Nephrolithiasis Pediatric GU Review UCSD Pediatric Urology George Chiang MD Sara Marietti MD Outlined from The Kelalis-King-Belman Textbook of Clinical Pediatric Urology 2007 (not for reproduction, distribution, or sale without consent)
  2. 2. Classification <ul><li>Enzyme Disorders </li></ul><ul><ul><li>Primary Hyperoxaluria </li></ul></ul><ul><ul><ul><li>Type I: glyoxylic aciduria </li></ul></ul></ul><ul><ul><ul><li>Type II: glyceric aciduria </li></ul></ul></ul><ul><ul><li>Xanthinuria </li></ul></ul><ul><ul><ul><li>1,8-Dihydroxyadeniuria </li></ul></ul></ul><ul><ul><ul><li>Lesch-Nyhan syndrome </li></ul></ul></ul>
  3. 3. Classification <ul><li>Renal tubular syndromes </li></ul><ul><ul><li>Cystinuria </li></ul></ul><ul><ul><li>Renal tubular acidosis </li></ul></ul><ul><li>Hypercalcemic states </li></ul><ul><ul><li>HyperPTH </li></ul></ul><ul><ul><li>Immobilization </li></ul></ul>
  4. 4. Classification <ul><li>Uric Acid Lithiasis </li></ul><ul><li>Enteric urolithiasis </li></ul><ul><li>Idiopathic calcium oxalate urolithiasis </li></ul><ul><ul><li>Hypercalciuria (Absorptive and Renal) </li></ul></ul><ul><ul><li>Hyperoxaluria </li></ul></ul><ul><ul><li>Hyperuricosuria </li></ul></ul><ul><ul><li>Hypocitraturia </li></ul></ul><ul><ul><li>Medications </li></ul></ul>
  5. 5. Classification <ul><li>Endemic bladder stone formation </li></ul><ul><li>Secondary urolithiasis </li></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Obstruction </li></ul></ul><ul><ul><li>Structural abnormalities </li></ul></ul><ul><ul><li>Urinary diversion procedures </li></ul></ul><ul><ul><li>Foreign body </li></ul></ul>
  6. 6. Metabolic Classification Calcium Stones Non-Calcium Hypercalciuria -Absorptive -Renal -Resorptive Uric Acid Hyperuricosuria Cystine Hyperoxaluria -Primary -Enteric Struvite Hypocitraturia -RTA I Amonium Acid Urate Hypomagnesuria Indinavir
  7. 7. Pathophysiology <ul><li>Formation of stone </li></ul><ul><ul><li>Urinary volume </li></ul></ul><ul><ul><li>pH </li></ul></ul><ul><ul><li>Presence of promoters or inhibitors of lithogenesis </li></ul></ul><ul><ul><li>Central event is supersaturation </li></ul></ul><ul><ul><li>Crystallization occurs via homogenous vs. heterogenous nucleation </li></ul></ul>
  8. 8. Pathophysiology Saturation Crystal growth and aggregation Supersaturation Crystal Retention Stone formation Nucleation
  9. 9. Presentation <ul><li>Renal colic occurs in 40-75% of children </li></ul><ul><li>Hematuria in 33-90% of children </li></ul><ul><li>Urethral stones present with terminal hematuria or inability to void </li></ul>
  10. 10. Presentation <ul><li>Factors </li></ul><ul><ul><li>Size of stone </li></ul></ul><ul><ul><li>Location of stone </li></ul></ul><ul><ul><li>Degree of obstruction </li></ul></ul><ul><ul><li>Presence of infection </li></ul></ul><ul><ul><li>Presence/absence of normal contralateral kidney </li></ul></ul>
  11. 11. Presentation <ul><li>H and P </li></ul><ul><ul><li>Prematurity (lasix, formulas) </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Concurrent illnesses (neoplasms, CF) </li></ul></ul><ul><ul><li>Recurrent skeletal fractures </li></ul></ul><ul><ul><li>Nutritional habits </li></ul></ul><ul><ul><li>Family history </li></ul></ul>
  12. 12. Imaging Radiopaque OR Radiolucent Calcium Oxalate Uric Acid Calcium phosphate Trimaterene Struvite Cystine Silica Xanthine
  13. 13. Laboratory Evaluation <ul><li>UA C&S </li></ul><ul><li>Serum electrolytes, BUN, and Cr </li></ul><ul><li>CBC </li></ul><ul><li>Serum for Ca, phosphorous, magnesium and PTH </li></ul><ul><li>2 xUrine collection after acute stone episode </li></ul><ul><ul><li>Volume, pH, calcium, uric acid, creatinine, sodium, oxalate, citrate, and cystine </li></ul></ul><ul><li>75% of all pediatric stones are calcium oxalate </li></ul>
  14. 14. Metabolic Classification Calcium Stones Non-Calcium Hypercalciuria -Absorptive -Renal -Resorptive Uric Acid Hyperuricosuria Cystine Hyperoxaluria -Primary -Enteric Struvite Hypocitraturia -RTA I Amonium Acid Urate Hypomagnesuria Indinavir
  15. 15. Hypercalciuria <ul><li>Absorptive </li></ul>GI ABSORPTION PLASMA CA PTH URINARY CA
  16. 16. Absorptive Hypercalciuria <ul><li>Type I (Diet Independent) </li></ul><ul><ul><li>High urinary calcium despite diet </li></ul></ul><ul><li>Type II (Diet dependent) </li></ul><ul><ul><li>Responds to calcium restriction </li></ul></ul><ul><li>Type III (phosphate leak) </li></ul><ul><ul><li>Low serum phosphate with increased Vit D and increased GI absorption </li></ul></ul><ul><li>Sarcoidosis </li></ul><ul><ul><li>Increased Vit D-->increased GI absorption </li></ul></ul>
  17. 17. Hypercalciuria <ul><li>Renal Leak </li></ul>Urinary Calcium PTH GI Absorption Bone Resoprtion Plasma Calcium
  18. 18. Hypercalciuria <ul><li>Resorptive (PTH) </li></ul>PTH Urinary Ca Bone Resorption GI Absorption Plasma Ca
  19. 19. Hypercalciuria Intestinal Absorption Fasting Urinary Ca PTH Serum Ca Resorptive Renal Absorptive High High High High High High High Low-nl High Normal Low-nl High
  20. 20. Hyperuricosuria <ul><li>Diet high in purines </li></ul><ul><li>Renal tubular defects </li></ul><ul><ul><li>Defect in renal tubular urate reabsorption </li></ul></ul><ul><li>Chemotherapy </li></ul><ul><li>Recurrent calcium oxalate stones (nidus) </li></ul><ul><li>Chemotherapy </li></ul><ul><li>Catabolic State </li></ul><ul><li>Urine pH <5.5 </li></ul><ul><li>Serum uric acid and calcium normal </li></ul>
  21. 21. Primary Hyperoxaluria <ul><li>Inherited disorder of glyoxylate metabolism </li></ul><ul><ul><li>Type I: Alanine-glyoxylate aminotransferase (1 in 120,000 births) </li></ul></ul><ul><ul><ul><li>Median age at presentation 5 yrs </li></ul></ul></ul><ul><ul><ul><li>Oxalate deposition occurs in bones </li></ul></ul></ul><ul><ul><ul><li>Screen all patients with stones for hyperoxaluria </li></ul></ul></ul><ul><ul><li>Type II </li></ul></ul><ul><ul><ul><li>D-glycerate dehydrogenase </li></ul></ul></ul><ul><ul><ul><ul><li>ESRD less common </li></ul></ul></ul></ul>
  22. 22. Primary Hyperoxaluria <ul><ul><li>ESRD </li></ul></ul><ul><ul><ul><li>50% of patients by age 15 and 80% by age 30 </li></ul></ul></ul><ul><ul><li>Therapy </li></ul></ul><ul><ul><ul><li>High urinary flow </li></ul></ul></ul><ul><ul><ul><li>Pyridoxine supplements </li></ul></ul></ul><ul><ul><ul><li>Liver/Kidney Transplant </li></ul></ul></ul>
  23. 23. Enteric Hyperoxaluria Bowel Disorder Fat malabsorption Excess fats bind to intestinal Ca Insufficient calcium to bind oxalate Unbound oxalate
  24. 24. Hypocitraturia <ul><li>Citrate is potent stone inhibitor </li></ul><ul><li>Caused by </li></ul><ul><ul><li>acidosis (RTA) </li></ul></ul><ul><ul><li>Hypokalemia </li></ul></ul><ul><ul><li>High animal protein diet </li></ul></ul><ul><ul><li>UTI </li></ul></ul>
  25. 25. RTA <ul><li>Type I </li></ul><ul><ul><li>Defect in distal tubule to excrete acid </li></ul></ul><ul><ul><li>Dx with systemic acidosis and urine pH>5.5 </li></ul></ul><ul><ul><li>Osteomalacia in children </li></ul></ul><ul><ul><li>Infants: growth retardation/vomitting/diarrhea </li></ul></ul><ul><li>Type II </li></ul><ul><ul><li>Defect in bicarb reabsorption (nephrocalcinosis not seen) </li></ul></ul><ul><li>Type IV </li></ul><ul><ul><li>Nephrocalcinosis not seen </li></ul></ul>
  26. 26. Type I RTA <ul><li>May be a secondary manifestation </li></ul><ul><ul><li>Sjogren’s, Wilson’s, PBC, Jejunoileal bypass </li></ul></ul><ul><li>Hypokalemic,hyperchloremic metabolic acidosis </li></ul><ul><li>Diagnostic workup indicated when nephrocalcinosis or recurrent nephrolithiasis </li></ul><ul><li>Ammonium chloride load testing (urinary pH should fall below 5.5) </li></ul><ul><li>Stones composed of calcium phosphate </li></ul>
  27. 27. Calcium Stones Misc <ul><li>Immobilization of children is most common cause of secondary hypercalciuria </li></ul><ul><li>Hypomagnesuria increases solubility of Ca, phosphate </li></ul><ul><ul><li>Most common cause is IBD </li></ul></ul>
  28. 28. Metabolic Classification Calcium Stones Non-Calcium Hypercalciuria -Absorptive -Renal -Resorptive Uric Acid Hyperuricosuria Cystine Hyperoxaluria -Primary -Enteric Struvite Hypocitraturia -RTA I Amonium Acid Urate Hypomagnesuria Indinavir
  29. 29. Uric Acid Lithiasis <ul><li>5% of calculi in pediatric patients </li></ul><ul><li>Orange (can be mistaken for blood) </li></ul><ul><li>Dysfunction of tubular reabsorption </li></ul><ul><ul><li>Wilson’s disease </li></ul></ul><ul><ul><li>Fanconi syndrome </li></ul></ul><ul><li>Overproduction of uric acid </li></ul><ul><ul><li>Lesch-Nyhan (deficiency of hypoxanthine-guanine phosphoribodyl transferase) </li></ul></ul><ul><ul><ul><li>Neurological disabilties, present between 3-12 “orange sand in diaper” </li></ul></ul></ul><ul><ul><li>Type I glycogen storage disease </li></ul></ul><ul><ul><li>Myeloproliferative disorders </li></ul></ul>
  30. 30. Uric Acid Lithiasis <ul><li>Increased intake </li></ul><ul><ul><li>Uricosuric drugs (probenecid, salicylate) </li></ul></ul><ul><li>Chronic diarrheal syndromes (net alkali defecit and lowered urine volume) </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Increasing oral fluid intake </li></ul></ul><ul><ul><li>Urinary alkalinization pH 6.5 to 7.0 </li></ul></ul><ul><ul><li>Allopurinal (but can lead to xanthine stones) </li></ul></ul>
  31. 31. Cystinuria <ul><li>Autosomal recessive disorder </li></ul><ul><li>1 in 15,000 live births </li></ul><ul><li>1-3% of children with metabolic urolithiasis </li></ul><ul><li>Defective transport of cystine, ornithine, lysine and arginine </li></ul><ul><li>Treatment </li></ul><ul><ul><li>High fluid intake (<300 mg cystine/L of urine) </li></ul></ul><ul><ul><li>Urinary alkalinzation </li></ul></ul><ul><ul><li>D-peniclliamine or Thiola (better tolerated) </li></ul></ul><ul><ul><li>Captopril </li></ul></ul>
  32. 32. Xanthinuria <ul><li>Enzymatic deficiency of xanthine dehydrogenase </li></ul><ul><ul><li>Urolithiasis, arthropathy, myopathy, crystal nephropathy, or renal failure </li></ul></ul>
  33. 33. Xanthinuria <ul><li>Enzymatic deficiency of xanthine dehydrogenase </li></ul><ul><ul><li>Urolithiasis, arthropathy, myopathy, crystal nephropathy, or renal failure </li></ul></ul>
  34. 34. Infection Stones <ul><li>2-3% of stones in pediatric population </li></ul><ul><li>Urinary pH >6.8 (urease) </li></ul><ul><li>Proteus, pseudomonas, klebsiella, streptococcus, mycoplasma </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Hemiacidrin irrigation </li></ul></ul><ul><ul><li>Acetohydroxamic acid (urease inhibitor) </li></ul></ul>
  35. 35. Misc Stones <ul><li>Triamterene stones </li></ul><ul><li>Sulfadiazine stones </li></ul><ul><li>Indinavir stones </li></ul>
  36. 36. Dietary Recommendations <ul><li>Maintain urine output >2 L/day or >20 cc/kg/day </li></ul><ul><li>No added salt </li></ul><ul><li>Avoid calcium restriction </li></ul><ul><li>Avoid excessive protein intake </li></ul><ul><li>5 servings per day of high potassium </li></ul><ul><li>Daily allowance of phosphorous/magnesium </li></ul>
  37. 38. Pediatric GU Review II Endourology for stone disease
  38. 39. Etiology/Epidemiology <ul><li>1 in 1000 to 1 in 7600 pediatric admissions </li></ul><ul><li>Spontaneous passage rate of 66% </li></ul><ul><li>Most pediatric stones are calcium oxalate </li></ul><ul><li>Anatomic abnormalities are discovered in 10-40% of children evaluated for stones </li></ul>
  39. 40. Etiology/Epidemiology <ul><li>Common urine abnormalities: </li></ul><ul><ul><li>Hypercalciuria </li></ul></ul><ul><ul><li>Hypocitraturia </li></ul></ul><ul><ul><li>Hypomagnesuria </li></ul></ul><ul><ul><li>Low urine volume (goal 35 cc/kg/day) </li></ul></ul><ul><li>Conservative management for stones <4 mm </li></ul><ul><li>Proactive treatment of stones >5 mm should be considered </li></ul>
  40. 41. Treatment Options <ul><li>ESWL </li></ul><ul><ul><li>Up to 75-98% stone free rates at 3 months with stones up to 2.5 cm </li></ul></ul><ul><ul><li>Children can pass larger stone fragments than adults </li></ul></ul><ul><ul><li>Long term functional studies on pediatric patients show no change in RPF or height after 4 yrs </li></ul></ul><ul><ul><li>Abdominal/flank discomfort in early post-op period should have eval for hematoma/obstruction </li></ul></ul><ul><ul><li>Hemoptysis in small stature and skeletal deformities (styrofoam padding) </li></ul></ul><ul><ul><li>Prone positioning may be necessary </li></ul></ul>
  41. 42. Treatment Options <ul><li>ESWL relative contraindications </li></ul><ul><ul><li>Morbid obesity </li></ul></ul><ul><ul><li>Large stone burden </li></ul></ul><ul><ul><li>Increased stone density </li></ul></ul><ul><ul><li>Congenital skeletal/renal abnormalities </li></ul></ul><ul><ul><li>Previously failed ESWL </li></ul></ul>
  42. 43. Treatment Options <ul><li>Ureteroscopy </li></ul><ul><ul><li>First reported in 1929 by Young </li></ul></ul><ul><ul><li>2 types of ureteroscopes: mini-rigid and flexible </li></ul></ul><ul><ul><li>Varying lengths </li></ul></ul><ul><ul><li>Distal tip as small as 4.7 Fr </li></ul></ul><ul><ul><li>Working channel 3.6 Fr </li></ul></ul>
  43. 44. Treatment Options <ul><li>Ureteroscopy: Instruments </li></ul><ul><ul><li>Stone retrieval devices can vary </li></ul></ul><ul><ul><ul><li>Size, position, and condition (impacted?) </li></ul></ul></ul><ul><ul><li>Grasping forceps will disengage from a stone if it is lodged (more effective for solitary stone) </li></ul></ul><ul><ul><li>Helical basket for steinstrasse </li></ul></ul><ul><ul><li>Nitinol baskets for caliceal stones and lower pole stones </li></ul></ul>
  44. 45. Treatment Options <ul><li>Intracorporeal lithotripsy </li></ul><ul><ul><li>Ultrasonic lithotripsy (1953) </li></ul></ul><ul><ul><li>Ballistic (pneumatic) </li></ul></ul><ul><ul><li>Electrohydraulic (EHL) </li></ul></ul><ul><ul><li>Laser (1992) </li></ul></ul>
  45. 46. Treatment Options <ul><li>Ureteroscopy technique </li></ul><ul><ul><li>Dilation required in up to 30% </li></ul></ul><ul><ul><ul><li>Graduated single shaft dilator from 6 to 10 Fr (dilate to 2 Fr sizes greater than diameter of endoscope) </li></ul></ul></ul><ul><ul><ul><li>May require passive dilation with stent </li></ul></ul></ul><ul><ul><ul><li>Smallest access sheath 9.5 Fr </li></ul></ul></ul><ul><ul><li>Presence of previous reimplant can require initial cannulation with actively deflecting guidewire </li></ul></ul><ul><ul><ul><li>Recurrent reflux after URS has never been reported </li></ul></ul></ul><ul><ul><li>Intrarenal access after UPJ repair is straightforward </li></ul></ul><ul><ul><li>Impacted stones may require dislodging into proximal dilated ureter for lithotripsy </li></ul></ul>
  46. 47. Treatment Options <ul><li>Percutaneous Endourology </li></ul><ul><ul><li>11 Fr and 15 Fr peel away sheaths have been used </li></ul></ul><ul><ul><li>A 24 Fr adult defect equals a 72 Fr defect in a child </li></ul></ul><ul><ul><li>A larger sheath is necessary for treatment of larger stones >3 cm </li></ul></ul><ul><ul><li>Multiple punctures may be needed </li></ul></ul><ul><ul><li>Upper pole access can cause pneumo/hydrothorax </li></ul></ul><ul><ul><li>Uncontrolled hemorrhage refractory to a tamponade balloon requires angiography </li></ul></ul><ul><ul><li>Dilutional hyponatremia is possible </li></ul></ul>
  47. 48. Treatment Strategies <ul><li>Renal Calculi </li></ul><ul><ul><li>ESWL for stones <1 cm </li></ul></ul><ul><ul><ul><li>Contraindication with UPJ obstruction, caliceal diverticulum, or infundibular stenosis </li></ul></ul></ul><ul><ul><ul><li>Less effective for ectopic or horseshoe kidneys </li></ul></ul></ul><ul><ul><ul><li>Overall, best suited for solitary renal stones <1.5 cm not contained within an abnormal lower pole calyx or abnormal renal anatomy </li></ul></ul></ul>
  48. 49. Treatment Strategies <ul><li>Renal Calculi </li></ul><ul><ul><li>Percutaneous approach </li></ul></ul><ul><ul><ul><li>Intrarenal stones >1 cm, multiple large calculi, urinary tract malformations, previous reconstruction </li></ul></ul></ul><ul><ul><ul><li>?Sandwich approach </li></ul></ul></ul><ul><ul><li>Laparoscopy with failure of percutaneous access </li></ul></ul>
  49. 50. Treatment Strategies <ul><li>Ureteral calculi </li></ul><ul><ul><li>ESWL effective 54-100% </li></ul></ul><ul><ul><li>Ureteroscopic lithotripsy is 77-100% </li></ul></ul><ul><ul><ul><li>Orifice dilation only necessary 33% </li></ul></ul></ul><ul><ul><ul><li>Becoming first line for ureteral stones </li></ul></ul></ul><ul><ul><li>Percutaneous approach with impacted stones, significant hydro, or urosepsis </li></ul></ul>
  50. 51. Treatment Strategies <ul><li>Bladder Calculi </li></ul><ul><ul><li>Open cystolithotomy </li></ul></ul><ul><ul><li>Cystolithopaxy </li></ul></ul><ul><ul><ul><li>EHL can perf augmented bladder </li></ul></ul></ul><ul><ul><li>Percutaneous approach </li></ul></ul>
  51. 52. Question #1 <ul><li>What are the 5 most important chemical abnormalities in stone formers? </li></ul>Low urinary volume Hyperoxaluria Hyperuricosuria Hypocitraturia Hypercalciuria
  52. 53. Question #2 <ul><li>What is the strongest chemical promoter of stone production? </li></ul>Oxalate
  53. 54. Question #3 <ul><li>What are the three types of hypercalciuria? </li></ul>Resorptive Renal Absorptive
  54. 55. Question #4 <ul><li>What is the medication of choice for renal hypercalciuria? </li></ul>Thiazide diuretics augment calcium reabsorption in the distal and proximal tubules
  55. 56. Question #5 <ul><li>The stones least suitable for ESWL are: </li></ul><ul><li>Calcium oxalate dehydrate </li></ul><ul><li>Uric Acid </li></ul><ul><li>Struvite </li></ul><ul><li>Calcium oxalate monohydrate </li></ul><ul><li>Cystine </li></ul>
  56. 57. Question #6 <ul><li>The ideal treatment for large staghorn calculi >2.5 cm is: </li></ul><ul><li>ESWL </li></ul><ul><li>Multi Access PCNL </li></ul><ul><li>ESWL followed by PCNL </li></ul><ul><li>PCNL followed by ESWL </li></ul><ul><li>Anatrophic pyelolithotomy </li></ul>
  57. 58. Question #6 <ul><li>The factors predicting stone clearance after ESWL for lower pole stones include all except: </li></ul><ul><li>Infundibulopelvic angle </li></ul><ul><li>Laterality </li></ul><ul><li>Renal function </li></ul><ul><li>Infundibular length </li></ul><ul><li>Infundibular width </li></ul>
  58. 59. Question #7 <ul><li>The best treatment for a 2 cm renal stone with a UPJO </li></ul><ul><li>Open pyelolithotomy </li></ul><ul><li>URS </li></ul><ul><li>ESWL </li></ul><ul><li>PCNL with endopyelotomy </li></ul><ul><li>Retrograde endopyelotomy with laser litho </li></ul>
  59. 60. Question #7 <ul><li>The mechanism of stone fragmentation during ESWL include all the following except </li></ul><ul><li>Compression fracture </li></ul><ul><li>Spallation </li></ul><ul><li>Cavitation </li></ul><ul><li>Passive Expansion </li></ul><ul><li>Dynamic fatigue </li></ul>
  60. 61. Question #8 <ul><li>What is the most common renal structural abnormality identified in patients with calcium containing stones? </li></ul><ul><li>UPJ obstruction </li></ul><ul><li>Infundibular obstruction </li></ul><ul><li>Calyceal obstruction </li></ul><ul><li>Medullary sponge kidney </li></ul><ul><li>Proximal tubule obstruction </li></ul>
  61. 62. Question #9 <ul><li>Adverse reactions to D-penicllamine include </li></ul><ul><li>Constipation </li></ul><ul><li>Diarrhea </li></ul><ul><li>Melena </li></ul><ul><li>Visual disturbances </li></ul><ul><li>Liver toxicity </li></ul>
  62. 63. Question #10 <ul><li>Urease-producing bacteria hydrolyze urea to which of the following? </li></ul><ul><li>Uric acid </li></ul><ul><li>Carbon monoxide </li></ul><ul><li>Carbon dioxide </li></ul><ul><li>Ammonium and carbon dioxide </li></ul>
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