Investigations and management of urolithiasis
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This document summarizes investigations and management of urolithiasis or kidney stones. It discusses basic laboratory tests on urine and blood to identify stones, as well as various imaging techniques like KUB X-rays, ultrasounds, IVUs and CTUs. Management options are outlined depending on stone size and location, including observation, chemolysis, shockwave lithotripsy, ureteroscopic lithotripsy, percutaneous procedures, and open surgery. The document emphasizes the importance of preventing recurrent stones through lifestyle changes, medications, and treating underlying metabolic issues.
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Investigations and management of urolithiasis
- 1. Investigations and Management of Urolithiasis Amalina Mohd Daud (0917298)
- 2. Outline of Presentation • Investigations • Basic Laboratory: Urine and Blood • Imaging: KUB Xray, Ultrasound, IVU and CTU • Radionuclide study: DTPA scan • Management • Preventions
- 3. Urine • UFEME • Urine culture • 24 hour urine collection
- 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. 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. 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. KUB X-ray
- 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. KUB Ultrasound - Dilated ureteral tunnel - Stone and shadowing distal to the stone
- 10. Imaging: IVU • Provide anatomical and functional informations • Size and location of the stone • Presence and severity of obstructions • Renal and ureteral abnormalities
- 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. Preliminary Film Look for radiopaque stone before contrast injected
- 14. 5 minute film -Determine symmetrical excretion - Determine need for more contrast
- 15. 15 minute film Delineate pelvicalyceal junction and ureter
- 16. Release / 25 minute film Demonstrate distended bladder
- 17. Post- Micturition Film -demonstrate bladder emptying success -demonstrate return of dilated upper urinary tract with relief of bladder pressure
- 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. 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. Non-contrast -Evaluate for calculi, fat- containing lesions and parenchymal calcifications - Stone in middle segment of right ureter
- 21. Radionuclide study : DTPA • Diethylene triamine pentaacetic acid • Evaluate obstruction, perfusion, GFR quantifications • Adv: relative split function of both kidney
- 22. DTPA
- 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. Management
- 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. 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. 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. 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. Endoscopic Removal of Stone
- 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. 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. 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. 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. Bladder stone • Options • Transurethral cystolitholapaxy • Percutaneous suprapubic cystolitholapaxy (paeds) • Method • Cystoscope fragment stone stone remove via cystoscope
- 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. • Complications • Ureteric obstructions (bulky fragments) ureteral stent prior to ESWL • Urosepsis prophylactic antibiotic prior to ESWL (currently not needed)
- 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. 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. 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. 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. Prevention
- 43. Preventions
- 44. Thank you =)