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Investigations and management of urolithiasis

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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 urolithiasis

  1. 1. Investigations and Management of Urolithiasis Amalina Mohd Daud (0917298)
  2. 2. Outline of Presentation • Investigations • Basic Laboratory: Urine and Blood • Imaging: KUB Xray, Ultrasound, IVU and CTU • Radionuclide study: DTPA scan • Management • Preventions
  3. 3. Urine • UFEME • Urine culture • 24 hour urine collection
  4. 4. 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
  5. 5. 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)
  6. 6. 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
  7. 7. KUB X-ray
  8. 8. 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
  9. 9. KUB Ultrasound - Dilated ureteral tunnel - Stone and shadowing distal to the stone
  10. 10. Imaging: IVU • Provide anatomical and functional informations • Size and location of the stone • Presence and severity of obstructions • Renal and ureteral abnormalities
  11. 11. 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
  12. 12. Preliminary Film Look for radiopaque stone before contrast injected
  13. 13. Immediate Film Nephrogram
  14. 14. 5 minute film -Determine symmetrical excretion - Determine need for more contrast
  15. 15. 15 minute film Delineate pelvicalyceal junction and ureter
  16. 16. Release / 25 minute film Demonstrate distended bladder
  17. 17. Post- Micturition Film -demonstrate bladder emptying success -demonstrate return of dilated upper urinary tract with relief of bladder pressure
  18. 18. 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
  19. 19. 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
  20. 20. Non-contrast -Evaluate for calculi, fat- containing lesions and parenchymal calcifications - Stone in middle segment of right ureter
  21. 21. Radionuclide study : DTPA • Diethylene triamine pentaacetic acid • Evaluate obstruction, perfusion, GFR quantifications • Adv: relative split function of both kidney
  22. 22. DTPA
  23. 23. Relative split function
  24. 24. 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
  25. 25. Management
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. Endoscopic Removal of Stone
  31. 31. No evidence of obstruction or infection Observation Surgical - stone <5mm - Asymptomatic patients • persistent, recurrent or severe pain • Obstruction or infection • Risk of pyonephrosis and urosepsis • Solitary kidney • Bilateral obstruction
  32. 32. No evidence of Obstruction or Infection Location <5mm 5-10mm 1-2cm >2cm Urethra Pass spontaneously Open Vesicolithotripsy Bladder Pass spontaneously Transurethral Cystolitholapaxy Ureter MET URS ESWL MET URS ESWL URS Open/ Laparoscopic uretherolithotomy Kidney MET ESWL RIRS MET ESWL RIRS PCNL # At any size, chemolysis is important
  33. 33. Chemolysis Stone 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
  34. 34. 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
  35. 35. Bladder stone • Options • Transurethral cystolitholapaxy • Percutaneous suprapubic cystolitholapaxy (paeds) • Method • Cystoscope  fragment stone  stone remove via cystoscope
  36. 36. 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
  37. 37. • Complications • Ureteric obstructions (bulky fragments)  ureteral stent prior to ESWL • Urosepsis  prophylactic antibiotic prior to ESWL (currently not needed)
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. Prevention
  43. 43. Preventions
  44. 44. Thank you =)

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