3- Urinary stone disease_ Diagnosis, treatment, metabolic evaluation and prevention

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Questions and Answers

Which site is NOT typically associated with obstruction from kidney stones?

Ureter crosses over Internal iliac vessels

Ureteral Vesical Junction

Ureteral Pelvic Junction

Ureteral Prostatic Junction (correct)

What is a classic symptom associated with stone obstruction?

Persistent headaches

Loss of appetite

Constant dull pain in the lower back

Severe acute, colicky pain (correct)

Which laboratory test result indicates a possible urinary infection?

High potassium levels

Elevated blood glucose

Decreased calcium levels

Positive nitrites (correct)

In terms of spontaneous stone passage, which stone size has the lowest passing percentage?

7 mm Signup and view all the answers

What is the first-line diagnostic test for locating stones in the urinary system?

Non-contrasted CT Signup and view all the answers

When calculating the success of spontaneous passage, which factor is LEAST correlated?

Patient's age Signup and view all the answers

Which of the following symptoms is associated with irritation of the bladder lining?

Frequency of urination Signup and view all the answers

What percentage of stones measuring 4 mm will likely pass spontaneously?

77% Signup and view all the answers

What percentage of cases does avulsion occur approximately?

0.3% Signup and view all the answers

What additional tests are included in an extensive metabolic evaluation compared to an abbreviated evaluation?

24-hour urine collection for various parameters Signup and view all the answers

Which of the following is NOT a general dietary recommendation for stone prevention?

A high sodium diet Signup and view all the answers

Which condition increases the risk of ureteral strictures according to the outlined complications?

Impacted stones and perforations Signup and view all the answers

What is one of the specific dietary recommendations for someone with a low oxalate diet?

Avoiding nuts and rhubarb Signup and view all the answers

Which of the following is an indication for Percutaneous Nephrolithotomy (PCNL)?

Renal pelvis calculi > 2 cm Signup and view all the answers

What is a notable disadvantage of Extracorporeal Shock Wave Lithotripsy (ESWL)?

Patients must pass stone fragments Signup and view all the answers

Which condition serves as a relative contraindication for Shock Wave Lithotripsy (SWL)?

Large stones greater than 30 mm Signup and view all the answers

Which patient condition is NOT a contraindication for ESWL?

Staghorn calculi Signup and view all the answers

What is a common complication associated with Percutaneous Nephrolithotomy (PCNL)?

Hematoma formation Signup and view all the answers

What is considered the most common first-line treatment for renal calculi?

Extracorporeal Shock Wave Lithotripsy Signup and view all the answers

In what scenario is PCNL considered most advantageous?

Obstructed renal anatomy with large stones Signup and view all the answers

Which of the following statements about Steinstrasse is accurate?

Is a complication of ESWL in 4-9% of cases Signup and view all the answers

What must be ensured for an ideal candidate for ESWL?

Patient is fully informed and compliant Signup and view all the answers

What is the risk percentage of bleeding caused by transfusion?

3% Signup and view all the answers

Which procedure is commonly employed to stabilize a hemodynamically stable patient experiencing bleeding?

Placement of nephrostomy tampanode balloon catheter Signup and view all the answers

Which sign is NOT associated with bowel injury postoperatively?

Respiratory distress Signup and view all the answers

What is the most common site for colonic injury during procedures?

Left access Signup and view all the answers

What tool is used for lithotripsy during ureteroscopy?

Laser Signup and view all the answers

What is a common symptom postoperatively indicating renal pelvis laceration?

Flank pain Signup and view all the answers

What is the risk percentage of ureteral perforation when using semi-rigid URS?

1-15% Signup and view all the answers

Which complication associated with percutaneous access has a 10% risk of fluid in the pleura?

Above 12th rib Signup and view all the answers

What is a significant advantage of ureteroscopy?

High success rate of removal Signup and view all the answers

What is the treatment for ureteral false passage?

Stent placement Signup and view all the answers

Which of the following is NOT an indication for hospital admission?

Controlled pain with oral hydration Signup and view all the answers

What is the primary medical management for a patient undergoing a Trial of Passage?

Oral hydration Signup and view all the answers

Which treatment is indicated for patients with active infection before stone removal?

Antibiotics and drainage of the kidney Signup and view all the answers

What is the effect of alpha blockers like Tamsulosin in treating kidney stones?

Decreases time to stone passage Signup and view all the answers

Which intervention is NOT included in the treatment of kidney and ureteral stones?

Double J ureteral stent placement Signup and view all the answers

How often should a patient be re-evaluated with imaging during a Trial of Passage?

4-6 weeks Signup and view all the answers

What is the primary goal of using a nephrostomy tube in treating kidney stones?

To provide drainage of the kidney Signup and view all the answers

Which of the following options is a rare intervention for kidney and ureteral stones?

Open surgery Signup and view all the answers

What is the role of analgesics in the management of kidney stones?

To control pain associated with stones Signup and view all the answers

In the treatment strategy, which factor is considered when determining intervention options?

Stone size and location Signup and view all the answers

Study Notes

Urinary System Stone Disease

Diagnosis, treatment, metabolic evaluation, and prevention are key topics
The author is UĞUR BOYLU, M.D., Professor of Urology, Istiny University, Department of Urology, Liv Hospital Ulus, Istanbul.

Symptoms-1

Not all patients with stones experience symptoms
Stones become symptomatic when they cause obstruction and irritation
Obstruction sites include:
- Ureteral Pelvic Junction (UPJ)
- Ureter crossing internal iliac vessels
- Ureteral Vesical Junction (UVJ)
Obstruction can be associated with infection

Symptoms-2

Classic symptoms of obstruction include acute, colicky pain, which can be severe
Nausea and vomiting can accompany the pain
Pain location can pinpoint stone location (e.g., flank, abdominal, groin, or testicle)
Irritation of the urothelial lining can lead to hematuria (blood in urine), gross or microscopic
Irritation of bladder lining can cause frequency, urgency, and dysuria
If infection is present, fever can develop

Evaluation-1

Laboratory tests:
- Elevated white blood cell count (CBC)
- Elevated creatinine (BMP)
- Positive nitrites and leukocyte esterase in urine analysis (UA)
- Urine culture to confirm infection
- Blood cultures if febrile
Imaging:
- Non-contrast CT is the first-line diagnostic test
- Locate stone
- Determine stone size
- Identify signs of obstruction such as hydronephrosis and hydroureter
- KUB, intravenous pyelogram (IVP), and ultrasound (US)

Evaluation-2

Success of spontaneous stone passage is correlated with stone location and size.
Distal stones are more likely to pass than proximal stones
95% of stones less than 5 mm will pass within 40 days

Evaluation-3

Indications for hospital admission in cases of urinary stones:
- Fever
- Signs of infection (elevated WBC)
- Solitary kidney
- Intractable pain
- Unable to tolerate fluids due to nausea/vomiting
- Renal deterioration (elevated creatinine due to obstruction)

Treatment-1

Trial of Passage (Surveillance):
- Candidates: afebrile patients with controlled pain, no signs of infection or renal compromise
- Medical management:
  - Oral hydration
  - Analgesics (Tylenol, narcotics)
  - Alpha blockers (Tamsulosin) to relax ureteral muscle, increasing stone passage rates up to 44% -Decreases time to stone passage by ~2-4 days
  - Re-evaluate with imaging in ~4-6 weeks
If stone remains, intervention is necessary

Treatment-2

Patients with Active Infection:
- Initial treatment: Antibiotics, kidney drainage via
- ureteral stents, percutaneous nephrostomy tubes
- Proceed with stone removal after infection clearance

Treatment-3

Treatment strategy based on stone size and location
Options for kidney and ureteral stones include:
- Extracorporeal shock wave lithotripsy (ESWL)
- Percutaneous nephrolithotomy (PCNL) with lithotripsy
- Ureteroscopy with lithotripsy/extraction
Options for bladder stones include:
- Cystolitholapaxy
- Cystolithotomy (open surgery)

Treatment-4

ESWL:
- Indications: Non-obstructed renal or ureteral calculi ≤ 1.5-2 cm
- Contraindications: Pregnancy, coagulopathy, AAA (> 4 cm), cystine, or infectious stones (relative contraindication).
- Advantages: Non-invasive, outpatient
- Disadvantages: Patients may need to pass stone fragments, complications (Steinstrasse 4-9%, may require 2nd intervention).

Treatment-5

PCNL:
- Indications: Renal pelvis calculi ≥ 2 cm, staghorn calculi, proximal ureteral calculi ≥ 1 cm, UPJ obstruction
- Contraindications: Coagulopathy
- Advantages: High stone-free rate (renal stones ~95%, ureteral stones ~75%)
- Disadvantages: Anesthesia, overnight hospital stay, possibly requiring a ureteral stent or nephrostomy tube during the perioperative period.

Treatment-6

Complications with PCNL:
- Bleeding (risk of transfusion ~3%, hemodynamically unstable patients may need OR return)
- Pneumothorax/hydrothorax (risk increases above 12th rib)
- Bowel injury (~0.2% risk, colon injury more common in left access, intraoperative detection can include contrast in colon with nephrostogram, and signs include fecaluria, pneumaturia, peritoneal signs, fever, ileus, leukocytosis)
- Renal pelvis laceration/perforation

Treatment-7

Ureteroscopy (URS):
- Indications: Ureteral and lower pole renal stones, morbid obesity, bleeding diathesis, ectopic or horseshoe kidneys
- Tools: Semi-rigid or flexible ureteroscope, lithotripsy (laser, pneumatic, electrohydraulic, ultrasonic), stone grasper, and basket
- Advantages: Outpatient, high success rate (~95% with laser lithotripsy of ureteral stones)
- Disadvantages: Anesthesia, possible need for ureteral stent placement

Treatment-8

Complications of URS:
- Ureteral false passage (0.4-0.9%)
- Ureteral perforation (1-15%), more common with semi-rigid URS
- Avulsion (~0.3%), requires operative repair
- Ureteral strictures (0-4%), increased risk with impacted stone or perforation

Follow Up Care-1

Abbreviated Metabolic Evaluation: First-time, uncomplicated cases with solitary stones.
- UA, UCx, stone analysis, BMP, calcium, phosphorus, uric acid
Extensive Metabolic Evaluation: Recurrent episodes, differing metabolisms, non-calcium-based stones.
- 24-hour urine collection (pH, volume, sodium, potassium, citrate, uric acid, magnesium, oxalate, chloride, protein, creatinine, cystine).

Follow Up Care-2

Dietary Recommendations:
- Maintain adequate hydration (2-3 liters urine per day)
- Limit sodium intake
- Reduce animal protein intake
- Minimize oxalate intake (avoid foods high in oxalate)
- Moderate calcium intake (800-1000 mg/day)
Specific recommendations based on the metabolic evaluation

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Description

This quiz covers the key aspects of urinary system stone disease, including diagnosis, treatment, metabolic evaluation, and prevention. Focused on symptoms related to obstruction and irritation caused by stones, it provides insights into managing this condition effectively.