management of urinary calculus

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management of urinary calculus

  1. 1. DISCUSS THE MANAGEMENT OF URINARY CALCULUS DR BASHIR YUNUS SURGERY DEPARTMENT A.K.T.H 22/4/14 4/21/2014 1
  2. 2. OUTLINE INTRODUCTION o ANATOMY o EPIDEMIOLOGY o RISK FACTOR o TYPES o AETIOPATHOGENESIS PRESENTATION o EMERGENCY o ELECTIVE o ASYMPTOMATIC MANAGEMENT o RESUSITATION o HISTORY o EXAMINATION o DIFFERENTIALS o INVESTIGATION o TREATMENT FOLLOW-UP PREVENTION PROGNOSIS STONES IN SPECIAL SITUATIONS FUTURE TRENDS 4/21/2014 2
  3. 3. INTRODUCTION • Urinary calculus or stone along the urinary tract. The 3rd most common urological disease preceded only by UTI and prostate pathology. • Stone can be found anywhere along the genitourinary system, of various sizes with varying presentations. • Management of stones have been revolutionized by advancement in technology and it depends on the availability of equipment and expertise. 4/21/2014 3
  4. 4. ANATOMY 4/21/2014 4
  5. 5. ANATOMY • Anatomical narrowings:  Ureteropelvic junction  Crossing of the iliac artery  Juxtaposition of broad ligament or vas deference  Entering the bladder wall  Ureteric orifice 4/21/2014 5
  6. 6. EPIDEMIOLOGY • World wide distribution, commoner in developed countries also increasing developing countries. • Western Europe -2-3% of population • Nigeria incidence 7-34 per 100,000. 4/21/2014 6
  7. 7. Nigeria • Mshelia, 2005. Maiduguri, M:F 12:1 76.9% calcium stones • Ekwere, Calabar, high hospital incidence, 19.1 per 100,000. Attributed high sea food consumption. • Hassan, Zaria, Paediatric population 9.6 per 100,000. 59% congenital anomalies • Mbonu, Enugu, M:F 5:1 13 per 100,000 hospital population 80% due to obstruction. 4/21/2014 7
  8. 8. NIGERIA • S A AJI, S U ALHASSAN, A M MOHAMMAD, SA MASHI. KANO; 2011 • M:F 3:1 • Peaks at 3rd decade • Predominantly upper tract • Loin pain as the commonest symptoms 34.2% 4/21/2014 8
  9. 9. RISK FACTORS • FAMILY HISTORY: 25% of patient with recurrent calcium calculi have family history • DEHYDRATION: increase concentration and reduced solubility of urine constituent. Decrease fluid Intake, increase loss of fluid, hot arid region • CLIMATE: hot climate. • SEX: commoner in males. Testosterone increase endogenous oxalate production and oxaluria. oestrogen increase urinary citrate conc. Thereby preventing oxalate crystal deposition. 4/21/2014 9
  10. 10. RISK FACTORS • DIET: excessive intake of food containing purines, oxalate, calcium phosphate. • AFFLUENCE • STRESS • OCCUPATION: physicians and other white- collar workers, Catheters. • HARD WATER • MEDICATIONS- antihypertensive medication triamterene • CHANGES IN URINE PH; alkali- (ca, p), acid- (uric a, cystine) 4/21/2014 10
  11. 11. AETIOLOGY • METABOLIC CAUSES  hypercalcaemia o Primary hyperparathyroidism o Prolong immobilization o Vitamin D intoxication o Milk alkali syndrome o Sarcoidosis o Ectopic parathyroid hormone secretion – hypernephroma, bronchogenic ca.  Enzyme disorders o Xanthinuria o Primary hyperoxaluria  Renal tubular syndromes o Cystinuria o Renal tubular acidosis 4/21/2014 11
  12. 12. AETIOLOGY • METABOLIC  Hyperuricaemia o Idiopathic uric acid lithiasis o Gout o Myeloproliferative disorders o Low urinary output states o Protein catabolism • Leukemia • Cytotoxic chemotherapy 4/21/2014 12
  13. 13. AETIOLOGY • NON-METABOLIC  Obstruction – stasis, infection, stone formation.  Infection- urea splitting organisms; E coli, proteus, klebsella, Pseudomonas  Congenital anomalies ; medullary sponge kidneys, horseshoe kidney 4/21/2014 13
  14. 14. PATHOGENESIS • Explained by theories  NUCLEATION THEORY It state that stone originate from crystals or foreign body immersed in supersaturated urine.  MATRIX THEORY It postulate that matrix may act as a nidus for crystal aggregation or as a natural glue to adhere small crystals.  CRYSTAL INHIBITION THEORY It claims that calculi form owing to the absence or low concentration of urinary stone inhibitors. 4/21/2014 14
  15. 15. PATHOGENESIS INHIBITORS OF CRYSTALLIZATION • Magnesium • Citrate • Pyrophosphate • Orthophosphates • Nephrocalcin • Glycosaminoglycans • Mucopolysaccharides • Uropontin • Urinary peptides • Artificial urolithiasis inhibitors • Methylene blue • Phosphonate ions 4/21/2014 15
  16. 16. THEORIES • Fix particle theory o Randalls plaque -- renal papilla o Carr microliths -- lymphatics • Theory of mass precipitation • intranephronic precipitation • Crystallization Precipitation theory 4/21/2014 16
  17. 17. TYPES  CALCIUM OXALATE 60%  PHOSPHATE STONE 30% -forms staghorn cal. o CALCIUM PHOSPHATE o AMMONIUM MAGNESIUM PHOSPHATE o CALCIUM AMMONIUM MAGNESIUM PHOSPHATE(triple phosph)  URIC ACID AND URATE STONES 5-10% o More found in bladder than kidneys o Related to high standard diet  CYSTINE STONE 1-3% o May aggregate to form staghorn, recurrence is common 4/21/2014 17
  18. 18. TYPES • OTHERS o XANTHENE – def. of xanthene oxidase o INDINAVIR – ARV drug related o SILICATE o MATRIX o TRIAMTERENE STONES All are radiolucent 4/21/2014 18
  19. 19. CLINICAL PRESENTATION The clinical presentation of patient with urinary calculi depend mainly on the o site of stone o size of the stones, o unilateral or bilateral stone diseases, o presence or absence of associated infection 4/21/2014 19
  20. 20. PRESENTATION EMERGENCY ELECTIVE SILENT OR ASYMPTOMATIC COMPLICATIONS 4/21/2014 20
  21. 21. EMERGENCY o RENAL COLIC o It is a sudden acute, intense, agonizing, paroxysmal pain which begins in the renal angle, then radiates around the flank towards the bladder, testis in the male or labium majus in the female, or to the anterior or lateral aspects of the thigh. (T12-L2) o Patient rolls around as excruciating sharp pain superimposed upon a background of continuous discomfort (peristalsis pushing stone down). o It is often associated with shock, sweating and nausea or vomiting. o It may last only a few seconds or persist for up t0 48h. o It ends dramatically when the SlOne falls back into o the pelvis or into the bladder 4/21/2014 21
  22. 22. EMERGENCY o ACUTE URINE RETENTION o UROSEPSIS o CALCULUS ANURIA- 4/21/2014 22
  23. 23. ELECTIVE • PAIN : a dull or boring, ache in the loin, especially in the costo-vertebral (renal) angle, due to some obstruction of the pelvis. • HAEMATURIA ; usu after strenuous activity • FREQUENCY • PASSAGE OF STONE IN URINE • NON- SPECIFIC ; NAUSEA, VOMITING 4/21/2014 23
  24. 24. ASYMTOMATIC • They are discovered incidentally during routine investigations such as urinalysis and imaging for other disorders 4/21/2014 24
  25. 25. COMPLICATIONS • RENAL MASS o secondary hydronephrosis o squamous cell ca. – prolong irritation o Pyeonephrosis o Perinephric abscess o Renal abscess o Xantho granulomatous pyelonephritis • CHRONIC RENAL FAILURE • PERIURETHRAL ABSCESS/FISTULAE 4/21/2014 25
  26. 26. DIFFERENTIALS • Non urological o Appendicitis o Diverticulitis o Ectopic pregnancy,salphingitis,tortion of ovarian cyst o RupturedAAA o biliary colic • Urological o Pyelonephritis o Stricture,tumour,renal infarction o Testicular tortion 4/21/2014 26
  27. 27. MANAGEMENT • Depends on the mode of presentation • For emergency, patient is resusitated along side some investigation, before a definative procedure • Detail history, examination, and investigation are required for elective or asymtomatic presentation 4/21/2014 27
  28. 28. RESUSITATION ACUTE RENAL COLIC • PAIN – o ANALGESIC- NSAID OR NARCOTICS • Diclofenac 100mg 2doses usu suffice in acte attack • +/- antiemetic OR • Im pethidine 75mg + antiemetic or morphine • FLUID o Given iv, >3L/day if accompanied with vomiting Otherwise liberal fluid intake 4/21/2014 28
  29. 29. RESUSITATION • ACUTE URINE RETENTION o Small stones near the external meatus can be grasped with a grasper. o Stone in the prostetic urethra • Instill 2% lidocain jelly(allow for 5min) then push stone into the bladder using urethral catheter subsequent removed endoscopically o Stone in the penile urethra • External urethrotomy o Stone impacted in a fossa navicularis or external meatus • meatotomy • UROSEPSIS o IV Fluid resusitation for correction of hypotension if present o iv antibiotics 4/21/2014 29
  30. 30. RESUSITATION • When acute episode subsides, o Plain abdominal xray – 90% of stone o Abdominal USS – 10% stone, infected hydronephrosis, solitary obstructed kidney o Urine: Urinalysis, urine microscopy; microscopic haematuria 90%, wbc , ph, o Urgent U/E Cr- calculus anuria. • Patient may require nephrostomy for temporal diversion or relieve of obstruction 4/21/2014 30
  31. 31. RESUSITATION • INDICATIONS FOR URGENT INTERVENTION o WHEN THERE IS STONE OBSTRUCTION ASSOCIATED WITH INFECTION. o DECREASE RENAL FUCTION o CACULUS ANURIA- BILATRAL OBSTRUCTION, OBSTRUCTED SOLITARY KIDNEY o PYEONEPHROSIS 4/21/2014 31
  32. 32. ELECTIVE • DETAIL HISTORY o Risk factors o Aetiology o Complications • PHYSICAL EXAMINATION o May not reveal any significant finding o Hydronephrosis as renal angle mass o Tenderness; lumber or iliac o A large vesical stone may be felt on bimanual examination 4/21/2014 32
  33. 33. INVESTIGATIONS • DIAGNOSTIC o PLAIN X-RAY KUB- 90% of stones o ABD USS- 10% radiolucent (uric, xanthene) o IVU- Degree of obstruction o Degree of function o Confirms radio- opaque stones o Show non opaque stones as filling defect o Number of the kidneys o Where available, non contrast helical CT scan- gold standard • AETIOLOGY o Urinalysis-pH, rbc, microscopy- crystal sediments o STONE ANALYSIS – for stone passed o 24 hr urinary calcium (2.5-7.5mmol/24hrs)or uric acid 1g/, cystine 30- 50mg/, oxalate 40mg/ o Nitroprusside test: Urinary cystine concentration rarely exceeds 70mg %. 4/21/2014 33
  34. 34. • BLOOD CHEMISTRY • RETROGRAGED PYELOGRAM o is indicated if the kidney is nonfunctioning from acute obstruction • X-RAY OF SMALL BONES OF THE HAND o is taken if hyperparathyroidism is suspected when subperiosteal resorption and cystic areas may be seen • CYSTOSCOPY o It is necessary for the evaluation of lowcr urinary tract obstruction c.g. prostatic hypertrophy, bladdcr infection and visualization of non-opaque stonc.c;e.g. uric acid stone. 4/21/2014 34
  35. 35. TREATMENT • OPTIONS o CONSERVATIVE o SURGICAL o URETEROSCOPY o PCNL o ESWL • INTERVENTION DEPENDS ON; o SIZE OF STONE o SITE OF STONE o AVAILABILITY OF TREATMENT o ABNORMAL ANATOMY OF THE URINARY TRACT o PATIENT CHIOCE 4/21/2014 35
  36. 36. CONSERVATIVE • Small stones(<5 mm) • If stone size o <4mm 80%pass spontaneously o 4-6mm 50%pass spontaneously o >6mm only 10%pass spontaneously • More distal the better • Pain controlled • Absence of renal failure and sepsis 4/21/2014 36
  37. 37. CONSERVATIVE Conservative measures include: • 1- Encourage fluid intake ≥ than 3L/day. • 2- Analgesia (whether NSAID or centrally acting analgesia). • 3- Encourage exercise and movement. • 4-↓ salts intake. • 5- Alkalanization of urine. Review and ensure stone has passed Absence of pain does not confirm stone expulsion 4/21/2014 37
  38. 38. CONSERVATIVE Indications for intervention: • Failure of conservative treatment Intractable pain refractory vomiting or refractory haematuria. • Obstructing large size stone that affecting the renal function or renal parenchyma. OR Prolonged obstruction • Non-progressing calculus(impacted)> 2months • Infection • Stones >5mm 4/21/2014 38
  39. 39. OPEN SURGERY • Treat UTI if present before surgery • X-ray just before surgery to see position of stone. Surgery is indicated: o For obstruction with impaired renal function o Obstruction with infection o Stone >1cm o Stone <1cm with symptoms e.g severe pains, haematuria o Starghorn calculi o Solitary kidney o Bilateral obstruction 4/21/2014 39
  40. 40. OPEN SURGERY • PRINCIPLES o To preserve as much as possible of the functioning renal tissue and to prevent complications. o Anacsthcsia (by induction, halothane) may lead to decreased urine output after renal surgery in an severly dehydrated patient. Thus there is no place for hypatcnsive anaesthesia in renal surgery. • Special considerations o In bilateral kidney stone. operate on the most painful side first then on the other side. o In bilateral kidney stones with one non-functioning (bad) kidney, operate on the healthy side first then perform nephrectomy on the bad kidney. 4/21/2014 40
  41. 41. OPEN SURGERY. (a) Pyelolithotomy: The renal pelvis is incised and the stone removed from the pelvis or calyx. (b) Nephrolithotomy: An incision is made into the kidney substance to remove large stones.Hemorrhage is often severe. (c) Partial or total nephrectomy is required for a severely damaged kidney. (d) Ureterolithotomy: An incision is made in the ureter after it has been exposed and the stone removed through it. 4/21/2014 41
  42. 42. APPROACHES TO THE KIDNEY • Lumbar or simple flank incision. • Nagamatsu incision. • Thoracoabdominal incision. • Transperitoneal and retroperitoneal incisions. 4/21/2014 42
  43. 43. OPEN SURGERY 4/21/2014 43
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  45. 45. EXTRA CORPORIAL SHOCK WAVES (ESWL): treatment of choice for those patients with o renal or upper ureteric stones, o size(10-25 mm) and o those with failed conservative treatment. There are 2 types of shock waves emitters: o supersonic emitters and o fine amplitude emitters. Contra indications to ESWL: • 1. Pregnancy. • 2. Large abdominal aneurysm. • 3. Uncorrectable bleeding disorders 4/21/2014 45
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  50. 50. ESWL • Most stone fragments pass within 2-weeks period. • A 3-month follow-up KUB film helps direct the need for additional therapy. • Complications o Sepsis o Hematuria o Transient renal dysfunction o obstruction 4/21/2014 50
  51. 51. PERCUTANEOUS NEPHROLITHOTOMY(PCNL): Antegrade instrumentation of the upper urinary tract via percutaneous puncture. indications : • 1. Big renal stones (≥ 25 mm) –too large for ESWL • 2. Distal obstruction not cause by the stone: as PUJ obstruction. • 3. Stone in calyceal diverticulum. • 4. Lower pole renal stones where the success of ESWL is low. • 5. when there is contra indication for ESWL. 4/21/2014 51
  52. 52. Procedure of P.C.N.L:- • 1 Anesthesia, - GA,LA,ED cystoscopy ureteral catheter instillation of radiopaque dye to opacify the renal pelvicaliceal system(p.c.s). • 2 The patient should be placed in prone position . • 3- Under uss guide, the puncture site : few centimeters inferior and medial to the tip of the 12th rib until it reaches the renal pelvis and guide wire left in place. 4/21/2014 52
  53. 53. PCNL • 4-Dalitation of the tract done with metal or plastic daliators and nephroscopy sheath passed. • 5-Destruction of renal stones done with various lithotripters and removal of the fragments through nephroscopy tract. • Advantages: •Stone removal rates between 95-99 (difficult access/complete staghorn 80-85%) •Short hospitalisation(1-3days) •Minimal disability 4/21/2014 53
  54. 54. PCNL 4/21/2014 54
  55. 55. PCNL 4/21/2014 55
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  57. 57. PCNL Various types of lithotripters can be used for destruction and removal of renal stones as • electrohydrolic, • ultrasonic • laser probes lithotripters 4/21/2014 57
  58. 58. URETEROSCOPY : Mainly for treatment of ureteric stones especially in the fallowing situations o 1- Mid and lower ureteric stones with failure of conservative expectant treatment where ESWL is contraindicated. o 2- Upper ureteric stones with failure of conservative and ESWL treatment. o 3- Impacted upper ureteric stones where ESWL is contra indicated. 4/21/2014 58
  59. 59. URETEROSCOPE • A small endoscope, which may be rigid, semirigid, or flexible, is passed into the bladder and up the ureter to directly visualize the stone. • directly extracted using a basket or grasper or broken into small pieces using various lithotrites (eg, laser, ultrasonic, electrohydraulic, ballistic). 4/21/2014 59
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  63. 63. Dormia basket 4/21/2014 63
  64. 64. TREATMENT OPTIONS FOR BLADDER CALCULI 1.Endoscopic vesico litholapaxy : • Cystolitholapaxy allows most stones to be broken and subsequently removed through a cystoscope. • By cystoscope with use of various types of lithotripters as mechanical, ultrasonic, electrohydrolic or laser lithotripters. 2. Open vesicolithotomy : • It is mainly used for very large vesical stones and in children where transurtheral surgery carry high risk of uretheral stricture. • It also indicated where facilities for endoscopic surgery are not present. 4/21/2014 64
  65. 65. PREVENTION General measures o Hydration: aim at urine output >2L/24hrs o Dietary restriction • Decrease protein intake • Decrease dietary calcium • Decrease sodium intake • Decrease oxalate intake • Avoid excess vitamin c • Decrease phosphate Increase dietary fibre 4/21/2014 65
  66. 66. PREVENTION Specific measures o Thiazide diuretics i.e. for calcium oxalate stones o Orthophosphates o Sodium cellulose phosphates: this tends to bind to calcium thereby inhibiting the intestinal absorption of calcium o Allopurinol:→ decreases the production of uric acid. o Citrates e.g. sodium potassium citrate, potassium citrate. o Magnesium 4/21/2014 66
  67. 67. FOLLOW UP • History – symptoms • Physical examination • Metabolic analysis • Assessment of renal function – U/ECr, USS • Ensure preventive measures 4/21/2014 67
  68. 68. PROGNOSIS • Renal calculi may recur especially if preventive measures are not rigorously pursued. 4/21/2014 68
  69. 69. STONES IN SPECIAL SITUATION RENAL TRANSPLANTATION • Urinary stones are rare. • Classic renal colic absent (Perirenal nerves are severed at the time of renal harvesting ) • Presumptive diagnosis of graft rejection –high index of suspicion • With radiographic and ultrasonic evaluation is the correct diagnosis made • Treatment; 4/21/2014 69
  70. 70. PREGNANCY • Renal colic is the most common nonobstetric cause of acute abdominal pain during pregnancy • Calculi are relatively rare, with an incidence 1:1500 pregnancies. • Caution is taken regarding radiation exposure (especially in the 1st trimester), medications, anesthesia, and surgical intervention. • About 90% of symptomatic calculi present during the 2nd and 3rd trimesters. • Investigations; renal uss and limited abdominal x-rays with appropriate shielding. • Treatment ;Temporal- double-J ureteral stent or a percutaneous nephrostomy tube under local anesthesia. 4/21/2014 70
  71. 71. STONES IN SPECIAL SITUATION • OBESITY Obesity is a risk factor for the development of urinary calculi. • Surgical bypass procedures can cause hyperoxaluria. • Problems: limitation in physical examination, diagnostic and treatment options, misguide incisions, prone positioning on lithotripters • Ultrasound examination is hindered by the attenuation of ultrasound beams. • CT, fluoroscopy tables, and lithotripters all have weight limitations • Treatment : open surgery 4/21/2014 71
  72. 72. STONES IN SPECIAL SITUATION PEDIATRIC PATIENTS • Urinary calculi are unusual in children. • Children born prematurely and given furosemide while in the neonatal ICU are at increased risk of developing urinary stone disease. • Possibilties of genitourinay abnormalities or inherited genetic disorder such as cystinuria, distal renal tubular acidosis, or primary hyperoxaluria. • A full and thorough metabolic evaluation should be undertaken. Stone analysis is particularly helpful in directing these investigations. • Treatment may be limited by endoscope size. Preliminary data show no change in renal growth after ESWL. • PCNL has become an established treatment. 4/21/2014 72
  73. 73. STONES IN SPECIAL SITUATION • DYSMORPHIA Severe skeletal dysmorphia • Congenital (spina bifida, myelomeningocele, cerebral palsy) or Acquired (arthritis, traumatic spinal cord injuries) and concurrent urinary calculi • Problems: o Positioning for ESWL or percutaneous approaches. eg Calculi on the concave side in a patient with severe scoliosis may eliminate percutaneous puncture access between the rib and the posterosuperior iliac spine. o Risks for hypercalciuria • Immobilization • relative dehydration; inability to drink without resistance 4/21/2014 73
  74. 74. FUTURE TRENDS • Biodegradable ureteric stents • Improved instrumentation • Increased use of day-case surgery • Greater surgical intervention o Flexible ureteroscopy • More critical use of ESWL with fewer retreatments 4/21/2014 74
  75. 75. CONCLUSION • Urinary calculi is of increasing burden in developing Countries with urbanization. There is limitation in the management, due to limited resources. Most presentation in our environment are infected. Mainstay of treatment in most developing countries still remain surgery. 4/21/2014 75
  76. 76. REFERENCES • SMITH’S GENERAL UROLOGY, “URINARY STONE DISEASE” 17TH EDITION, McGraw-Hill 2008 246-275 • E.A Badoe ET AL, “Principles and Practice of surgery including pathology in the tropics” 4th edition, Assembly of God Literature Center ltd, 2009. • M.A.R Al-Fallouji; “Postgraduate Surgery the candidate guide”. 2nd Edition. Rced Educational and Professional Pub. Ltd 1998 • Baley and Love’s, “ Short Practice of Surgery” 25th edition, Edward Arnold Ltd, 2008 1295-1301 • CAMPBELL-WALSH UROLOGY, “Urinary Lithiasis” 10th EDITION Saunders, an imprint of Elsevier Inc. 2012. Vol 2; • . 4/21/2014 76
  77. 77. REFERENCES • Aji S A, S Alhassan et al. “Urinary Stone Disease in Kano, North Western Nigeria” Nigerian Medical Journal. April - June 2011. Vol. 52 Issue 2 • S.A.H Rizvi et al; “The management of stone disease” BJU Internation 2002, 89(suppl. 1), 62-68 • Turk, T Knoll, et al “Guidelines on Urolithiasis” European Association of Urology. 2008 • A.STEWART AND A DJOYCE. “Modern management of renal colic” Trends in Urology Gynaecology & Sexual Health May/June 2008 4/21/2014 77

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