This document provides an overview of the evaluation and management of ureteric stones. It discusses the typical signs and symptoms of ureteric stones including flank pain radiating to the groin. Imaging options like ultrasound, KUB, CT are outlined. Treatment depends on factors like stone size and location, and may include pain control, conservative management, medical expulsive therapy, or active stone removal procedures like ESWL, URS, or PCNL. Prevention emphasizes adequate hydration and dietary modifications.
2. Learning Objectives
1. List the signs/symptoms and differential
diagnoses of an acute stone episode
2. Describe the imaging studies available
to diagnose ureteral calculi.
3. List the classes of medications effective
for treating the pain of renal colic.
4. Outline the basic treatment options for
ureteral stone
5. Describe the clinical scenarios requiring
urgent decompression of a ureteral
stone.
6. List the basic principles of stone
prevention
3. URINARY TRACT STONES
The 3rd most common urological
disease preceded only by UTI and
prostate pathology.
5. CLINICAL MANIFESTATIONS
The clinical presentation of patient
with urinary calculi depend mainly on
the site, size, laterality of stone
diseases, and presence or absence of
infection
Presentation maybe
EMERGENCY
ELECTIVE
SILENT OR ASYMPTOMATIC
COMPLICATIONS
6. Clinical Manifestations
Obstructing calculi in the upper urinary
tract cause an extreme crescendo like
pain in the flank that generally radiates
laterally around the abdomen to the
corresponding groin and testicles in
males and labia major in females
7. Clinical Manifestations
Colic nature of the pain
◦ Rapid onset
◦ Unable to achieve comfortable position (writhing)
Radiates from flank to groin
◦ Testis/labia
Associated nausea/vomiting
Hematuria
◦ Gross, microscopic (present in 90%; absence doesn’t
r/o)
Irritative LUTS
◦ May indicate stone near the UVJ/distal ureter
Associated with fever if UTI
Anuria
Tenderness present in the loin or no findings in
abdomen
9. Investigations
after careful history taking and physical
examination :
Labs:
◦ Creatinine& Urea (renal failure)
◦ Urinalysis (microscopy is gold standard to look
for crystals)
◦ CBC&diff (Look for ↑WBC,
◦ Pregnancy Test (HCG) in females
10. Imaging:
◦ Ultrasound -
◦ KUB (Kidney-Ureter-Pelvis)=PUT
◦ Non-contrast CT UT (NCCT)
◦ IVP - more or less historical or in remote settings
11.
12. KUB film
- Advantages:
◦ 80-90% of stones are radio-opaque
◦ Minimal radiation
Disadvantages:
◦ Radiolucent stone
◦ Easy to miss mid-ureteral stones over the
sacrum
◦ Bowel gas can obscure its efficacy
◦ Cannot differentiate , Stones,Calcified LN
,
◦ Sensitivity: 50-70%
38. Non-contrast CT
Advantages:
◦ All stone types are visible except indinavir
Sensitivity - 97%; Specificity - 96%
◦ Rapid,Readily available
◦ Does not require contrast
◦ Other pathologies identified
◦ Information about stone and collecting
system obtained
• Stone density (Stones >500HU are opaque
on KUB)
45. Medical Expulsive Therapy
(MET)
Administration of a drug to facilitate the
passage of the stone
25 – 30 % more chances of spontaneous
passage
Decreased time to pass the stone.
Less surgical intervention.
Should follow-up with urology within 1-2 weeks
Drugs
Alpha blocker – Tamsulosin
Calcium channel blocker
Corticosteroids
drink >2L of water/day
47. INDICATION OF ACTIVE STONE REMOVAL
Persistent pain despite adequate
medication;
Persistent obstruction with risk of
impaired renal function;
Stone with urinary tract infection;
Bilateral obstruction;
Obstructing calculus in a solitary
functioning kidney.
48. LINE OF TREATMENT
ESWL
Percutaneous Nephrolithotomy
Ureterorenoscopy
Open / Laparoscopic Approach to
stones
50. Extracorporeal Shockwave
Lithotripsy (ESWL)
Least invasive
Conscious sedation
Fragments stones that the patient then
passes
High patient satisfaction
May require more time to become stone free
Renal calculi <2cm or ureteral calculi <1cm
Contra-indications
Pregnancy
Bleeding Disorder/anticoagulation (NSAIDS
pre-op)
Febrile UTI
Obstruction Distal to the stone being treated
51. SWL success depends on:
Stone Size (Better if <1cm)
Stone Location (Better if renal pelvic,
upper ureter)
Stone Density/ Composition (Better if
HU<1000)
◦ Hounsfield unit density on NCCT
Patient Habitus (Better if skin-to-stone
distance <10cm)
Worse if associated renal anomalies:
◦ UPJ Obstruction
◦ Horseshoe kidney
52.
53. Ureteroscopic (URS)
Advantages:
◦ Near 100% stone free rate
◦ Low retreatment rates
◦ Treatment available in most centres
Disadvantages:
◦ General or spinal anesthesia is usually required
◦ Ureteral stent (DJ) may be left
Stent symptoms are bothersome to patients
◦ Lower patient satisfaction
Typically for ureteral calculi and SWL
failures
54. Stone Prevention:
General Advice
Increase Hydration to 2-3L per day to achieve
daily urine output of 2.5L
Diet:
◦ Maintain normal calcium intake (1000-1200mg with
meals)
Used to advice low calcium diets – Proven to be false
◦ Minimize foods high in oxalate (Spinach, peanut,
rhubarb)
◦ Minimize salt (<2300mg/d) and animal protein
◦ Increase fiber, vegetables and citrus-rich fruits
Consider urinary alkalinization:
◦ Mainly for uric acid and cystine stones
◦ Potassium citrate - preferred
◦ Sodium citrate - alternative
55. Conclusions
Once stone detected – should be removed
Patients with colic – relief of pain is the priority.
Obstruction and infection – immediate attention.
Preventive measures - to avoid recurrence .