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?

<p>7 mm (D)</p> Signup and view all the answers

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

<p>Non-contrasted CT (D)</p> Signup and view all the answers

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

<p>Patient's age (A)</p> Signup and view all the answers

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

<p>Frequency of urination (C)</p> Signup and view all the answers

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

<p>77% (A)</p> Signup and view all the answers

What percentage of cases does avulsion occur approximately?

<p>0.3% (C)</p> Signup and view all the answers

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

<p>24-hour urine collection for various parameters (A)</p> Signup and view all the answers

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

<p>A high sodium diet (D)</p> Signup and view all the answers

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

<p>Impacted stones and perforations (A)</p> Signup and view all the answers

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

<p>Avoiding nuts and rhubarb (B)</p> Signup and view all the answers

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

<p>Renal pelvis calculi &gt; 2 cm (B)</p> Signup and view all the answers

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

<p>Patients must pass stone fragments (B)</p> Signup and view all the answers

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

<p>Large stones greater than 30 mm (D)</p> Signup and view all the answers

Which patient condition is NOT a contraindication for ESWL?

<p>Staghorn calculi (A)</p> Signup and view all the answers

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

<p>Hematoma formation (C)</p> Signup and view all the answers

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

<p>Extracorporeal Shock Wave Lithotripsy (C)</p> Signup and view all the answers

In what scenario is PCNL considered most advantageous?

<p>Obstructed renal anatomy with large stones (D)</p> Signup and view all the answers

Which of the following statements about Steinstrasse is accurate?

<p>Is a complication of ESWL in 4-9% of cases (D)</p> Signup and view all the answers

What must be ensured for an ideal candidate for ESWL?

<p>Patient is fully informed and compliant (B)</p> Signup and view all the answers

What is the risk percentage of bleeding caused by transfusion?

<p>3% (A)</p> Signup and view all the answers

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

<p>Placement of nephrostomy tampanode balloon catheter (D)</p> Signup and view all the answers

Which sign is NOT associated with bowel injury postoperatively?

<p>Respiratory distress (D)</p> Signup and view all the answers

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

<p>Left access (A)</p> Signup and view all the answers

What tool is used for lithotripsy during ureteroscopy?

<p>Laser (A)</p> Signup and view all the answers

What is a common symptom postoperatively indicating renal pelvis laceration?

<p>Flank pain (D)</p> Signup and view all the answers

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

<p>1-15% (C)</p> Signup and view all the answers

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

<p>Above 12th rib (D)</p> Signup and view all the answers

What is a significant advantage of ureteroscopy?

<p>High success rate of removal (A)</p> Signup and view all the answers

What is the treatment for ureteral false passage?

<p>Stent placement (D)</p> Signup and view all the answers

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

<p>Controlled pain with oral hydration (A)</p> Signup and view all the answers

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

<p>Oral hydration (D)</p> Signup and view all the answers

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

<p>Antibiotics and drainage of the kidney (B)</p> Signup and view all the answers

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

<p>Decreases time to stone passage (A)</p> Signup and view all the answers

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

<p>Double J ureteral stent placement (D)</p> Signup and view all the answers

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

<p>4-6 weeks (B)</p> Signup and view all the answers

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

<p>To provide drainage of the kidney (D)</p> Signup and view all the answers

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

<p>Open surgery (D)</p> Signup and view all the answers

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

<p>To control pain associated with stones (D)</p> Signup and view all the answers

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

<p>Stone size and location (A)</p> Signup and view all the answers

Flashcards

Urinary System Stone Symptoms

Symptoms of urinary stones occur when stones obstruct or irritate the urinary tract. Obstruction causes pain, while irritation leads to blood in the urine or other urinary problems.

Urinary Stone Pain Location

Stone location can indicate pain location; flank, abdominal or radiating to the groin or testicle.

Ureteral Obstruction

Blockage in the tube that carries urine from the kidney to the bladder

Diagnostic Test for Stones

Non-contrast CT scan is the initial diagnostic tool for finding stones and assessing urinary tract blockages.

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Stone Size and Spontaneous Passage

Smaller stones (under 5mm) are more likely to pass on their own than larger stones.

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Hematuria

Presence of blood in urine, often a symptom of urinary stones that irritate the urinary tract.

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Hydronephrosis

Kidney swelling due to urinary obstruction.

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Hydroureter

Swelling of the ureter due to blockages.

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Trial of Passage (Surveillance)

A method of managing kidney stones where patients are observed and managed medically rather than surgically, focusing on pain control and hydration while waiting for the stone to pass.

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Hospital Admission Indications

Conditions requiring a patient with kidney stones to be hospitalized. These include fever, infections signs (elevated WBC count), solitary kidney, intractable pain, inability to tolerate fluids, and renal deterioration (elevated creatinine due to obstruction).

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Alpha Blockers (e.g., Tamsulosin)

Medications that relax the muscles in the ureter, helping to pass stones more easily.

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Extracorporeal Shock Wave Lithotripsy (ESWL)

A non-invasive procedure that uses shock waves to break down kidney stones into smaller pieces that can be passed.

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Percutaneous Nephrolithotomy (PCNL)

A minimally invasive surgery to remove large kidney stones using small incisions.

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Ureteroscopy with Lithotripsy/Extraction

A procedure to remove ureteral stones using a small camera and tools inserted through the urethra and ureter.

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Double J ureteral stents

Tiny tubes placed into the ureter to keep it open and allow urine to flow; often used when infection is present or to allow drainage.

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Percutaneous nephrostomy tube

A tube inserted into the kidney through the skin to drain urine when the ureter is blocked.

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Cystolitholapaxy

Procedure treating bladder stones, often involving breaking the stone and removing it.

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Patient with Active Infection

Patients who show signs of infection in the kidneys or in the area of the kidney or ureter.

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PCNL Bleeding Risk

There is a 3% risk of needing a blood transfusion during a Percutaneous Nephrolithotomy (PCNL) procedure.

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Managing Hemodynamically Unstable Bleeding During PCNL

If severe bleeding occurs during PCNL and the patient's blood pressure and heart rate are unstable, they need to be immediately returned to the operating room.

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Managing Hemodynamically Stable Bleeding During PCNL

If bleeding is stable, options include placing a large nephrostomy tube, clamping the tube, using a nephrostomy balloon catheter, or performing angiography and embolization.

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PCNL Pneumothorax/Hydrothorax Risk

There is a 10% risk of pneumothorax or hydrothorax when accessing the kidney above the 12th rib during PCNL.

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PCNL Bowel Injury Risk

There is a ~0.2% risk of bowel injury during PCNL, with higher risk on the left side and in obese patients.

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Detecting Bowel Injury During PCNL

Contrast material in the colon during a nephrostogram can indicate a bowel injury during PCNL.

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Postoperative Signs of Bowel Injury After PCNL

Fecaluria, pneumaturia, abdominal pain, fever, ileus, and increased white blood cell count are signs of possible bowel injury after PCNL.

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Renal Pelvis Laceration/Perforation During PCNL

Damage to the kidney's collection area (renal pelvis) can occur during dilation of the percutaneous tract created for PCNL.

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Treating Renal Pelvis Laceration/Perforation After PCNL

Placement of a large nephrostomy tube until the tract heals is the usual treatment for a renal pelvis laceration or perforation.

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Common Symptom After Renal Pelvis Laceration/Perforation

Flank pain is a common post-operative symptom following a renal pelvis laceration or perforation.

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ESWL First Line Treatment

Extracorporeal shock wave lithotripsy (ESWL) is the most common initial treatment for kidney stones that are not obstructing urine flow and are smaller than 1.5-2 cm.

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ESWL Contraindications

ESWL is not suitable for all patients. Contraindications include pregnancy, bleeding disorders (coagulopathy), aortic aneurysms larger than 4 cm, and cystine or infected stones (relatively contraindicated).

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ESWL Advantages

ESWL has advantages like being minimally invasive, requiring only sedation, and being an outpatient procedure.

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ESWL Disadvantages

The main disadvantage of ESWL is that patients must pass the broken stone fragments, which might require multiple interventions.

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ESWL Complications

One potential complication of ESWL is 'Steinstrasse', where stone fragments form a blockage. Also, a hematoma (blood buildup) in the kidney or around it can occur.

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PCNL Indications

Percutaneous nephrolithotomy (PCNL) is indicated for larger stones in the kidney pelvis (over 2 cm), staghorn calculi (large, branching stones), proximal ureteral stones (over 1 cm), and upper urinary tract obstruction.

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PCNL Advantages

PCNL has high stone-free rates, reaching 95% for kidney stones and 75% for ureteral stones.

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PCNL Disadvantages

PCNL requires general anesthesia, an overnight hospital stay, and a temporary ureteral stent or nephrostomy tube.

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PNL in the Age of SWL

Percutaneous nephrolithotomy (PNL) is still used for complex cases even with the availability of shock wave lithotripsy (SWL). These cases include obstruction, large stone masses, anatomical abnormalities, SWL failure, cystine stones, and patients with obesity.

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PCNL Complications

PCNL can lead to complications like bleeding, infection, damage to the urinary tract, and even a need for further surgery.

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What is an avulsion?

An avulsion is a complete tear of the ureter from its attachment point, often caused by a large stone obstructing the ureter.

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What are the main causes of ureteral strictures?

Ureteral strictures are narrowings of the ureter, often caused by complications from stone treatment, such as previous surgery, stone impaction, or perforation.

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What is a 'Low Oxalate Diet'?

A low oxalate diet aims to reduce the intake of foods high in oxalate, a substance that can contribute to the formation of kidney stones. This includes foods like chocolate, tea, spinach, rhubarb, nuts, and beets.

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How much water should you drink to prevent kidney stones?

Aim to drink 2-3 liters (8-12 cups) of water per day to keep urine volume high and dilute potential stone-forming substances.

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What is the 'Abbreviated Metabolic Evaluation' for kidney stones?

This evaluation is recommended for a first stone episode, particularly if it was a single stone, uncomplicated, and resolved quickly.

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Study Notes

Urinary System Stone Disease

  • Diagnosis, treatment, metabolic evaluation, and prevention are key topics
  • The author is UÄžUR 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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Urinary Stone Disease Diagnosis, Treatment, Evaluation, and Prevention PDF

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.

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