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Renal calculi and obstructive uropathy.pptx
- 1. Renal stones &Obstructive uropathy Dr. Ankita Singh Assistant Professor Surgery LHMC, Delhi
- 2. Learning Objectives • Etiology& Pathogenesis • Pathology* • Laboratory & urinary findings • Complications Renal stones & Obstructive uropathy
- 3. Aetiology of Renalstones 1. Idiopathic calcium urolithiasis 2. Hypercalcaemic disorders 3. Renal tubular syndromes 4. Uric acid lithiasis 5. Enzyme disorders 6. Secondary urolithiasis 7. Other factors
- 4. 1. Idiopathic calciumurolithiasis • 70% of patients with urinary tract stones • Unexplained ↑ Calciuria • Normal serum Calcium • Often coexists with • Hyperoxaluria, hyperuricosuria, inhibitor deficiency & incomplete renal tubular acidosis
- 5. 2. Hypercalcaemic disorders a.Primary hyperparathyroidism • <5% patients with radio-opaque stones b. Prolonged immobilization • Bone resorption c. Milk-Alkali Syndrome • Nephrocalcinosis also d. Sarcoidosis e. Disseminated malignancy f. Cushing’s Disease g. Hyperthyroidism
- 6. 3. Renal tubularsyndromes a. Renal tubular acidosis • Type I- hypercalciuria, low urinary citrate excretion • Pure calcium phosphate stones mainly, Nephrocalcinosis b. Cystinuria • Autosomal recessive defect of A.A. transport – COLA • Stones: multiple, very hard & radio-opaque
- 7. 4. Uric acidlithiasis • 5-10% • Cause: excess excretion in urine, excessively acidic urine, low urine volume or idiopathic • Stones: multiple, hard, smooth, multifaceted • Pure- translucent, but mostly radio-opaque due to calcium
- 8. 5. Enzyme disorders a.Primary hyperoxaluria b. Xanthinuria c. 2,8 Dihydroadeninuria
- 9. 6. Secondary urolithiasis a.Secondary hyperoxaluria b. Dietary excess c. Infection d. Obstruction and stasis e. Medullary sponge kidney f. Urinary diversion g. Drugs
- 10. 7. Others • Geography •Climatic & seasonal factors • Water intake • Diet • Occupation: sedentary jobs in hot climate
- 11. Clinical features • Acuteureteric colic • 30-50 years, slightly male preponderance • +/- Renal pain • Dipstick hematuria • Confirmation by at earliest NCCT • Supplementary plain X Ray • Significance: 5 recognised narrowings ureter • Complications • Obstructive uropathy • Infection
- 12. Stone management 1. Emergencysetting 2. Elective setting • ESWL (Extracorporeal Shockwave Lithotripsy) • Ureteroscopy • PCNL (Percutaneous Nephrolithotomy) • Open stone surgery 3. Medical management
- 13. 1. Emergency setting •CT to confirm • <5mm stones pass spontaneously • Frequent pain, obstruction, infection or significant decline eGFR- early intervention • Urgent pain management: • In situ ESWL, Cystoscopy + ureteric stenting, primary ureteroscopic stone retrieval or laser tripsy • Obstructing calculus causing sepsis: • PCN placement, Cystoscopy + ureteric stenting
- 14. 2. Elective setting:ESWL • Commonest non invasive technique • Shockwaves used • Generated outside body • Focused on stones- USG/ fluoroscopy • Indication- <= 1.5cm stone • Limitations- impacted stone, infection, hard stones • Risk of hematuria, parenchymal hemorrhage, perirenal hematoma • Contraindications: obese, pregnant, anti coagulants • *several sessions may be required
- 15. 2. Elective setting:Uretero-reno scopy • Scope: rigid, semi- rigid or flexible • Entire urinary tract is accessible: diagnostic + therapeutic • Stone management • Wire retrieval basket- <6mm & distal ureter • Lithotripsy using USG, laser, electrokinetic energy sources • Mechanical disintegration by lithoclast • Complications: • Ureteric mucosal/ wall injury, perforation, extravasation, avulsion, stricture
- 16. 2. Elective setting:PCNL • Treat larger stones in renal pelvis, calyces, or sometimes proximal ureter • Technique: • Localization • Establishment of tract, dilatation • Working sheath placement- visualisation & stone management • Nephrostomy tube left • Indications: • Obstruction, obesity, lower calyx stones, composition • Complications: • Injury- kidney & vasculature, surrounding organs; sepsis; extravasation, retained stones
- 17. 2. Elective setting:Open Surgery • Total nephrectomy • Pyelo/ uretero/ nephro-lithotomy seldom done • Difficult post PCNL, infection, XGP
- 18. 3. Medical treatment:General • Goal: • prevent further stone formation OR growth of existing stones • Thus may have to be life long • Therapy for stone expulsion is controvertial • High fluid intake- aiming minimum 2.5L/d urine output • Elimination of dietary excess
- 19. 3. Medical treatment:Specific • Idiopathic calcium lithiasis • Thiazide diuretics, Orthophosphates, Cellulose phosphate, Citrate mixtures • Hypercalcaemic disorders • Thiazides, Orthophosphates, Corticosteroids (sarcoidosis) • RTA • Sodium or potassium bicarbonate/citrate • Cystinuria • Potassium citrate, D penicillamine, 6 MPG, Captopril • Uric acid lithiasis • Sodium bicarbonate/ potassium citrate- dissolve stone; Allopurinol
- 20. 3. Medical treatment:Specific.. • Primary hyperoxaluria • Pyridoxine, Neutral orthophosphates • Stone associated with infection • After surgical removal- antibiotic prophylaxis • Urinary acidification (ammonium chloride)
- 21.
- 22. Terminologies • Obstructive uropathy structuralor functional changes in the urinary tract that impede normal urine flow. • Obstructive nephropathy renal disease caused by impaired flow of urine or tubular fluid. • Hydronephrosis (HDN) aseptic dilatation of the urinary tract.
- 23. Classification Congenital • Can affecteither upper or lower urinary tract • Males • PUV (Postrerior Urethral Valve) or PUJO (Pelvi-ureteric junction obstruction) • Early gestation: dysplastic kidney • Later, low grade or unilateral: hydronephrosis with nephron loss Acquired • Can affect either upper or lower urinary tract • Based on causes • Cause: • extrinsic • Intrinsic: intra or extra luminal
- 25. Clinical features Unilateral hydronephrosis •MC- Women, right sided • Mild dull aching pain loin, often a dragging heaviness worsened by excessive fluid intake • Kidney may be palpable • Intermittent hydronephrosis (Dietl’s crisis) • USG- antenatal detection • Usually benign, but postnatal investigation is required to detect those with significant PUJ obstruction Bilateral hydronephrosis • Due to lower urinary obstruction • Bladder outlet obstruction symptoms predominant • Due to bilateral upper urinary tract obstruction • Idiopathic retroperitoneal fibrosis • Idiopathic PUJO • HDN of pregnancy: upto 20wks
- 26. Imaging • USG • IVU •helps only if there is significant function in obstructed kidney • Dilatation of extra renal pelvis, minor calyces- clubbed • RGU/P • Confirms site of obstruction • Isotope renography • Best test to confirm obstructive dilatation • DTPA or MAG-3
- 28. Treatment • Indications • Boutsof renal pain, increasing HDN, parenchymal damage & infection • Mild cases- to be followed serial USG & operated if dilation increases 1. Nephrectomy: <10% split function 2. Pyeloplasty 3. Endoscopic pyelolysis • Retrograde balloon dilatation • PUJ incision by hot wire over balloon • Laser incision • Percutaneous pyelolysis
- 29.