Urinary Stone Disease Diagnosis, Treatment, Evaluation, and Prevention PDF

Diagnosis, treatment, metabolic evaluation and prevention in urinary system stone disease U Ğ U R B OY L U , M. D. P R O F E S S O R O F U R O LO GY I S T I N Y E U N I V E R S I T Y, F A C U LT Y O F M E D I C I N E ,...

Diagnosis, treatment, metabolic evaluation and prevention in urinary system stone disease U Ğ U R B OY L U , M. D. P R O F E S S O R O F U R O LO GY I S T I N Y E U N I V E R S I T Y, F A C U LT Y O F M E D I C I N E , D E PA R T M E N T O F U R O L O G Y L I V H O S P I TA L U L U S , I S TA N B U L  Symptoms—1 — Not all patients with stones have symptoms — Stones become symptomatic when: 1. Cause obstruction and irritation ÷ Typical sites of obstruction: ¢ Ureteral Pelvic Junction (UPJ) ¢ Ureter crosses over Internal iliac vessels ¢ Ureteral Vesical Junction (UVJ) 2. Associated with infection  Symptoms—2 Classic symptoms: ¡ Obstruction Acute, colicky pain ÷ Can be severe ÷ May have associated nausea and vomiting ÷ Location of pain can suggest location of stone ¢ Flank ¢ Abdominal ¢ Radiate to groin or testicle ¡ Irritation urothelial lining Hematuria ÷ Gross or microscopic ¡ Irritation of bladder lining Lower urinary tract symptoms ÷ Frequency ÷ Urgency ÷ Dysuria If associated with infection Fever  Evaluation—1 — Laboratory tests: ¡ CBC—elevated white blood cell count ¡ BMP—elevated creatinine ¡ UA—positive nitrites, leukocyte esterase ÷ Order Urine culture ¡ If febrile—Blood cultures — Imaging: ¡ Non-contrasted CT ÷ 1st line diagnostic test ¢ Locate stone ¢ Determine stone size ¢ Identify signs of obstruction hydronephrosis and hydroureter ¡ KUB, Intravenous pyelogram (IVP), US  Evaluation—2 — Success of spontaneous stone passage is correlated with: Stone Approx % Mean width stones time to ¡ Location of stone: (mm) passed1 passage2 1 90% 8 days ÷ Distal > Proximal 2 85% 3 83% 11 days ¡ Stone size: 4 77% ÷ 95% of stones < 5 mm will pass 5 56% 22 days within 40 days 6 41% 7 30% 8 21% ? 9 3% 1 Urology 10(6); 1977. Am J Roentgenol 178:101;2002. 2J Urol 162:688; 1999  Evaluation—3 Which patients should undergo…. Trial of Passage (Surveillance) vs. Surgical Intervention — Indications for Hospital Admission: 1. Fever 2. Signs of infection a) Elevated WBC 3. Solitary kidney 4. Intractable pain 5. Unable to tolerate fluid secondary to nausea/vomitting 6. Renal deterioration a) Elevated creatinine attributed to obstruction  Treatment—1 Trial of Passage (Surveillance) — Patient candidates: ¡ Afebrile, pain controlled, no overt signs of infection or renal compromise — Medical management: ¡ Oral hydration ¡ Analegesics: tylenol, narcotics ¡ Alpha blockers: Tamulosin (Flomax) ÷ Relaxes ureteral smooth muscle ÷ Increases stone passage rates up to ~ 44% ÷ Decreases time to stone passage by ~2-4 days ÷ Decreases pain associated with stone passage — Re-evaluate with imaging ~4-6 weeks ¡ If stone remains….INTERVENTION becomes necessary  Treatment—2 Patients with Active Infection — Initial treatment: ¡ Antibiotics ¡ Drainage of kidney ÷ Ureteral stent Double J ureteral stents ÷ Percutaneous nephrostomy tube — Proceed with stone removal after infection has cleared Nephrostomy tube  Treatment—3 Treatment strategy based on…. Stone Size and Location — Options: ¡ Kidney and ureteral stones: 1. Extracorporeal Shock Wave Lithotripsy (ESWL) 2. Percutaneous nephrolithotomy with lithotripsy (PCNL) 3. Ureteroscopy with lithotripsy/extraction 4. Open surgery (rare) ¡ Bladder stones: 1. Cystolitholapaxy 2. Cystolithotomy (open surgery)  Treatment—4 ESWL Most common 1st line treatment for renal calculi — Indications: ¡ Non-obstructed renal or ureteral calculi < 1.5-2 cm — Contraindications: ¡ Pregnancy ¡ Coagulopathy ¡ AAA (> 4cm) ¡ Cystine, infectious stones (relative contraindication) — Advantages: ¡ Non-invasive ¡ Sedation only required ¡ Outpatient intervention — Disadvantages: ¡ Patients MUST pass stone fragments — Complications: ¡ Steinstrasse 4-9%—may require 2nd intervention ¡ Hematoma—renal/retroperitoneal  3RD GENERATION SWL SHOCK WAVE LITHOTRIPSY DORNIER HM-3 SECOND GENERATION MACHINES  SHOCK WAVE LITHOTRIPSY IDEAL CANDIDATES RELATIVE – Small stone (< 1.5 cm) CONTRAINDICATIONS Large stones – Mid or upper pole location Calcium oxalate > 20 mm – Normal renal anatomy Struvite > 30 mm – No distal obstruction Cystine stones Distal obstruction Poorly informed patients Contraindications to the use of ESWL: aortic and/or renal artery pregnancy aneurysms severe skeletal malformations uncontrolled blood coagulation severe obesity uncontrolled urinary tract infections  Treatment—5 PCNL — Indications: ¡ Renal pelvis calculi ~ > 2cm ¡ Staghorn calculi ¡ Proximal ureteral calculi ~ > 1cm ¡ UPJ obstruction — Contraindications: ¡ Coagulopathy — Advantages: ¡ High stone free rate ÷ Renal stones—95% ÷ Ureteral stones—75% — Disadvantages: ¡ Anesthesia ¡ Overnight hospital stay ¡ Ureteral stent and/or nephrostomy tube in perioperative period  STONE MANAGEMENT PERCUTANEOUS NEPHROLITHOTOMY  STONE MANAGEMENT PERCUTANEOUS NEPHROLITHOTOMY PNL IN THE AGE OF SWL Obstruction Large stone mass Anatomic abnormality SWL failure Cystine stones Certainty of results Obesity  Treatment—6 Complications with PCNL 1. Bleeding ¡ Risk of transfusion = 3% ¡ Hemodynamically unstable ÷ Return to the OR ¡ Hemodynamically stable ÷ Large diameter nephrostomy tube and clamp tube to tampanode bleeding ÷ Nephrostomy tampanode balloon catheter ÷ Angiography and embolization 2. Pneumothorax/Hydrothorax ¡ Percutaneous access: ÷ Above 12th rib—10% risk of fluid in pleura ÷ Above 11th rib—10% risk of pneumothorax/hydrothorax ¡ Signs/symptoms: Pleuritic chest/flank pain, loss of breath sounds, respiratory distress/desaturation  Treatment—6 Complications with PCNL 3. Bowel Injury ¡ ~0.2% risk ¡ Colonic injury more common ÷ Left access ÷ Morbidly obese ¡ Intraoperative detection: contrast in colon with nephrostogram ¡ Postoperative signs: Fecaluria, pneumaturia,peritoneal signs, fever, ileus, leukocystosis 4. Renal pelvis laceration/perforation ¡ Can occur with dilation of percutaneous tract ¡ Commonly detected intraoperatively ¡ Postoperatively: common symptom—flank pain ÷ Treatment: Placement of large bore nephrostomy tube until tract closes  Treatment—7 Ureteroscopy (URS) — Indications: ¡ Ureteral and lower pole renal stones ¡ Morbid obesity ¡ Bleeding diathesis ¡ Ectopic or horseshoe kidney — Tools (aka toys): ¡ Semi-rigid vs. flexible ureteroscope ¡ Lithotripsy: laser, pneumatic, electrohydralic, ultrasonic ¡ Extraction: stone grasper, basket — Advantages: ¡ Outpatient procedure ¡ High success rate of removal ~95% with Laser lithotripsy of ureteral stones — Disadvantages: ¡ Anesthesia ¡ Possible need for ureteral stent placement  STONE MANAGEMENT OPEN NEPHROLITHOTOMY – RARELY REQUIRED  Treatment—8 Complications of URS 1. Ureteral false passage 0.4-0.9% ¡ Entrance into ureteral orifice ¡ Passing guidewire around impacted stone ¡ Tx: Stent Ureteral orifice 2. Ureteral perforation 1-15% ¡ More common with semi-rigid URS ¡ Tx: Stent 3. Avulsion ~0.3% ¡ Basketing large stone in proximal or mid-ureter ¡ Complete avulsion requires operative repair 4. Ureteral Strictures 0-4% ¡ Late complication ¡ Increased risk with impacted stone, perforations Extravasation of contrast indicating perforation  Follow Up Care—1 — Abbreviated Metabolic evaluation ¡ First episode, solitary stone, uncomplicated course ¡ UA, Ucx, stone analysis, BMP, Ca2+, Phosphorus, uric acid ¡ Radiographic imaging — Extensive Metabolic evaluation ¡ Recurrent episodes, medical conditions alter metabolism, non-calcium based stones ¡ Same as abbreviated evaluation plus ÷ 24 hr urine collection (~2x): urinary pH, volume, sodium, potassium, citrate, uric acid, magnesium, oxalate, chloride, protein, creatinine, cystine  Follow Up Care—2 General Dietary Recommendations 1. Oral fluid intake ¡ Keep urine volume 2-3L/day 2. Low sodium diet 3. Low animal protein diet 4. Low oxalate diet ¡ Chocolate, tea, spinach, rhubarb, nuts, beets 5. Moderate calcium intake ¡ 800-1000 mg/day Specific recommendations based on metabolic evaluation