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- 1. Urolithiasis
- 2. πUrolithiasis (from Greek oΓ»ron-urine and lithos-stone) is the condition where urinary stones are formed or located anywhere in the urinary system. Urolithiasis
- 3. ο Kidney stones ο Ureteral stones ο Bladder stones ο Urethral stones Urolithiasis
- 4. π Urolithiasis is a common disease that is estimated to produce medical costs of $2.1 billion per year in the United States alone. π Urolithiasis has been a part of the human condition for millennia and have even been found in Egyptian mummies. Background
- 5. π Renal colic affects approximately 1.2 million people each year in USA and accounts for approximately 1% of all hospital admissions. π Most active emergency departments (EDs) manage patients with acute renal colic every day Background
- 6. π Urolithiasis occurs in all parts of the world π Alifetime risk: π 2-5% for Asia π 8-15% for the West π 20% for the Kingdom of Saudi Arabia π Hot Climate π Dietary habits π Hereditary factors Epidemiology
- 7. π The lower the economic status, the lower the likelihood of renal stones π Most at 20-49 years π Peak incidence at 35-45 years π Male-to-female ratio of 3:1 Epidemiology
- 8. π Four main chemical types: π Calcium stones π Struvite (magnesium ammonium phosphate) stones π Uric acid stones π Cystine stones Chemical Types
- 9. π Calcium stones account for 75% of Urolithiasis. π Radio-opaque π Multiple factors and etiologies π Mostly incidental Calcium stones
- 10. π Incidental π Hyperparathyroidism π Increased gut absorption of calcium π Renal calcium leak π Renal phosphate leak π Hperuricosuria π Hperoxaluria π Hypocitraturia π Hypomagnesuria Calcium Stone Known etiologies
- 11. Calcium Stone
- 12. π Account for 15% of renal calculi π Infectous stones π Gram-negative rods capable of splitting urea into ammonium, which combines with phosphate and magnesium π More common in females π Urine pH is typically greater than 7 Struvite (magnesium ammonium phosphate) stones
- 13. π Stag horn stones are non obstructive thus painless π Slowly growing π Discovered incidentally Struvite (magnesium ammonium phosphate) stones
- 14. π Account for 6% of renal calculi π Urine pH less than 5.5 π High purine intake eg. π organ meats π legumes π malignancy π 25% of patients have gout Uric acid stones
- 15. Uric Acid Stones
- 16. Uric Acid Stones
- 17. π 2% of renal calculi π Autosomal recessive trait π Intrinsic metabolic defect resulting in failure of renal tubular reabsorption of: π Cystine π Ornithine π Lysine π Arginine π Urine becomes supersaturated with cystine, with resultant crystal deposition Cystine stones
- 19. π 80 % pass spontaneously π 20% require hospital admission or intervention because of: π unrelenting pain π inability to retain enteral fluids π proximal UTI π inability to pass the stone π renal failure Prognosis
- 20. Prognosis π Recurrence rates after an initial episode of ureterolithiasis: π 14% at 1 year π 35% at 5 years π 52% at 10 years
- 21. History The presentation is variable. π Patients with urinary calculi may report π Pain π Infection π Hematuria π Asymptomatic
- 22. Silent Kidney stones π Small nonobstructing stones in the kidneys only occasionally cause symptoms. π If present, symptoms are usually moderate and easily controlled.
- 23. π The passage of stones into the ureter is associated with classic renal colic because of: π subsequent acute obstruction π proximal urinary tract dilation π ureteral spasm π Acute renal colic is probably the most excruciatingly painful event a person can endure Obstructive ureteral stone
- 24. Classic Renal Colic π Acute onset of severe flank pain radiating to the groin π Gross or microscopic hematuria π Nausea, and vomiting not associated with an acute abdomen in 50%
- 25. π Staghorn calculi are often relatively asymptomatic. π Branched kidney stone occupying the renal pelvis and at least one calyceal system. π Manifest as infection and hematuria. Staghorn stone
- 26. Acute renal failure π Asymptomatic bilateral obstruction π Solitary Kidney with obstructive stone
- 27. Location and characteristics of pain from ureteral stones π Depends on the level of obstruction and its degree: π ureteropelvic junction π pelvic brim π ureterovesical junction
- 28. UPJ Stone π Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin
- 29. Ureteral Stone π Cause abrupt, severe, colicky pain in the flank and ipsilateral lower abdomen π with radiation to the testicles or the vulvar area. π Intense nausea, with or without vomiting, usually is present.
- 30. Upper ureter π Tends to radiate to the flank and lumbar areas
- 31. Mid Ureter π Cause pain that radiates anteriorly and caudally. π Can easily mimic appendicitis on the right or acute diverticulitis on the left.
- 32. Distal Ureter and UVJ stones π Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female π At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis, such as: π urinary frequency π dysuria
- 34. Bladder Stones π Usually asymptomatic and are passed relatively easily during urination. π Rarely, a patient reports positional urinary retention (obstruction precipitated by standing, relieved by recumbency).
- 35. Phases of an attack The entire process typical lasts 3-18 hours Acute phase: peak in most patients within 2 hours of onset (30 min to 6 hours) Constant Phase 1- 4 hours maximum 12 hours Relief phase 1.5-3 hours
- 36. π Dramatic costovertebral angle tenderness π unremarkable abdominal evaluation π painful testicles but normal-appearing π constant body positional movements (eg, writhing, pacing) π Tachycardia π Hypertension π Microscopic hematuria Physical exam
- 37. π The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone, although confirmatory tests are usually performed. Diagnosis
- 38. π The recommended based on EUA recommendations: π Urinary sediment/dipstick test: To demonstrate blood cells π Serum creatinine level: To measure renal function Labarotary Testing
- 39. π May be helpful: π CBC in febrile patients π Serum electrolyte assessment in vomiting patients π 24-Hour urine profile on outpatient basis Additional Lab Tests
- 40. π Noncontrast abdominopelvic CT scan: The imaging modality of choice for assessment of urinary tract disease, especially acute renal colic. π IV contrast and delayed images might be required in selected cases Imaging studies
- 41. π Renal ultrasonography: π Renal stone π Hydronephrosis or ureteral dilation π Misses 30 % of stones π Plain abdominal radiograph (flat plate or KUB) misses 40 % of stones Imaging studies
- 42. Imaging studies π IVP (urography) historically, the criterion standard π In rare select situations: π Plain renal tomography π Retrograde pyelography π Nuclear renal scanning
- 43. Management
- 44. Emergency Renal Colic π IV access to allow : π Fluid π Analgesics: π Paracetamol π NSAID π Opiod π Antiemetic π In case of infection: π Urine culture π Blood culture accordingly e.g. febrile π Antibiotics
- 45. Approach Considerations π In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis. π These include: π Evident infection with obstruction π A solitary functional kidney π Bilateral ureteral obstruction π Renal failure
- 46. Important π The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection. π Pyelonephritis π Pyonephrosis π Urosepsis π Early recognition and immediate surgical drainage are necessary in these situations
- 47. Approach Considerations π The size of the stone is an important predictor of spontaneous passage. π A stone less than 4 mm in diameter has an 80% chance of spontaneous passage; this falls to 20% for stones larger than 8 mm in diameter
- 48. Approach Considerations π Hospital admission is clearly necessary when any of the following is present: π Oral analgesics are insufficient to manage the pain. Intractable vommiting Ureteral obstruction from a stone occurs in a solitary or transplanted kidney. Bilateral ureteral obstruction Ureteral obstruction from a stone occurs in the presence of π a urinary tract infection (UTI) π Fever π Sepsis π Pyonephrosis π π π π
- 49. Approach Considerations π Relative indications to consider for a possible admission include comorbid conditions π diabetes π dehydration π renal failure π immunocompromised state π perinephric urine extravasation π pregnancy
- 50. Approach Considerations Most patients with acute renal colic can be treated on an ambulatory basis.
- 51. Approach Considerations π Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage
- 52. Clinic Follow up π Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home. π Arrangements should be made for follow-up with a urologist in 2-3 days.
- 53. Active medical expulsive therapy π Paracetamol PRN for pain with or without Codeine π NSAID PRN for pain π Oral opiod analogue for severe pain π Alpha blockers π Antiemetic PRN for nausea and/or vommiting π Prednisone 20 mg twice daily for 6 days π With MET, stones 5-8 mm in size often pass, especially if located in the distal ureter.
- 54. Approach Considerations π An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume.
- 55. Emergency Advice π Patients should be told to return for : π fever π uncontrolled pain π uncontrolled vomiting π Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis
- 56. π General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention. Approach Considerations
- 57. Approach Considerations π Larger stones (ie, β₯ 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure. π Such patients require mandatory urology follow up
- 58. Approach Considerations π About 15-20% of patients require invasive intervention eventually as emergency or electively due to: π stone size π continued obstruction π Infection π intractable pain
- 59. Indications for Surgery π The primary indications for surgical treatment include: π Pain π Infection π Obstruction π Indications for urgent intervention: π Obstruction complicated by evident infection π Obstruction complicated by acute renal failure π Solitary kidney π Bilateral obstruction
- 60. Surgical options π Obstruction relief: π Ureteral stent insertion π Percutaneous nephrostomy π Definitive surgical treatment: π ESWL π Ureteroscopy π PCNL π Open, laparoscopic and robotic pyelo-lithotomy, ureterolithotomy, cystolithotomy π Open anatrophic nephrolithotomy
- 61. Surgical options π For an obstructed and infected collecting system secondary to stone disease π Emergency surgical relief is required with no contraindications: π percutaneous nephrostomy for critical patients π ureteral stent placement for stable patients
- 62. Surgical options π The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques π Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases
- 63. Surgical options π ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones. π The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management
- 64. Ureteral Stent π Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction. π Relieves renal colic pain even if the actual stone remains. π Dilate the ureter, making ureteroscopy and other endoscopic surgical procedures easier to perform later.
- 65. Percutaneous nephrostomy π Indicated if stent placement is inadvisable or impossible. π In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus
- 66. Extracorporeal shockwave lithotripsy π ESWL, the least invasive of the surgical methods of stone removal π Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments π It is especially suitable for stones that are smaller than 2 cm and lodged in π the upper or middle calyx π the upper ureter
- 67. Extracorporeal shockwave lithotripsy π The patient, under varying degrees of anesthesia π The shock head delivers shockwaves developed from an π Electrohydraulic π Electromagnetic π piezoelectric source
- 68. Ureteroscopy π Ureteroscopic manipulation of a stone is a commonly applied method of stone removal π A small endoscope, which may be π Rigid π Semirigid π Flexible π is passed into the bladder and up the ureter to directly visualize the stone
- 69. Ureteroscopy π Flexible ureteroscopy allows tackling of even lower calyceal stones π Stones are fragmented using π Swiss lithoclast π Laser π Ultrasonic lithotripter π Stones are retrieved using a stone basket
- 70. Percutaneous nephrostolithotomy π Percutaneous procedures are generally reserved for large and/or complex renal stones and failures from the other 2 modalities π Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter
- 71. Percutaneous nephrostolithotomy π In some cases, a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney.
- 72. Open Surgery π Open surgery has been used less and less often since the development of the previously mentioned techniques π It now constitutes less than 1% of all interventions. π Disadvantages include π longer hospitalization π longer convalescence π increased requirements for blood transfusion.
- 73. Approach Considerations π Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence, including: π multiple stones π personal or family history of previous stone formation π stones at a younger age π residual stones after treatment
- 74. Medical Therapy for Stone Disease π Urinary calculi composed predominantly of calcium cannot be dissolved π medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation
- 75. Medical Therapy for Stone Disease π Uric acid and cystine calculi can be dissolved with medical therapy. π Suitable option in patients with uric acid stones who do not require urgent surgical intervention π Is based on alkalization of the urine.
- 76. Medical Therapy for Stone Disease π Sodium bicarbonate can be used as the alkalizing agent π But potassium citrate is usually preferred because of the availability of slow-release tablets and the avoidance of a high sodium load
- 77. Medical Therapy for Stone Disease π The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 6.5 and 7.0.
- 78. Chemoprophylaxis π Prophylactic therapy might include: π most importantly, augmentation of fluid intake. π limitation of dietary components π addition of stone-formation inhibitors or intestinal calcium binders π avoid excessive salt and protein intake
- 79. Chemoprophylaxis Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents
- 80. Long-Term Monitoring π Metabolic evaluation is done by a typical 24-hour urine determination of: π urinary volume π pH π specific gravity π Calcium π Citrate π Magnesium π Oxalate π Phosphate π uric acid.
- 81. Long-Term Monitoring π Most common findings are π Hypercalciuria π Hyperuricosuria π Hyperoxaluria π Hypocitraturia π low urinary volume
- 82. Chemoprophylaxis π Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine.
- 83. Chemoprophylaxis If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones, allopurinol (300 mg qd) is recommended
- 84. Chemoprophylaxis π Pharmaceuticals that can bind free cystine in the urine: π D-penicillamine π 2-alpha-mercaptopropionyl-glycine π Help reduce stone formation in cystinuria. π Captopril has been shown to be effective in some trials
- 85. Dietary Measures π In almost all patients in whom stones form, an increase in fluid intake and, therefore, an increase in urine output is recommended. π This is likely the single most important aspect of stone prophylaxis π The goal is a total urine volume in 24 hours in excess of 2 liters.
- 86. Dietary Measures π The only other general dietary guidelines are to avoid excessive salt and protein intake. π Moderation of calcium and oxalate intake is also reasonable π Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders, most importantly osteoperosis.