Folusho Ogunfiditimi DM MPH PAC

Administratve Director

Adult Clinical Services and Advanced Practice Provider

DMC Urology

Describe the risk factors and causes of Renal and Ureteral Calculi

Identify the various types of Renal and Ureteral Calculi

Demonstrate the medical and surgical treatment of Renal and Ureteral Calculi

Highlight the complications related to various Renal Calculi

Discuss the role of PAs in Stone management

Pure causes are unknown

Risk Factors are well defined Hypercalciuria

Hyperparathyroidism

Hypercalcemia

Primary Hyperoxaluria

12 Men 5 Women

Increasing prevalence

1 in 11 people 50 reoccurrence

Composition of stones well known

Causes are still uncertain

Urinary Supersaturating (SS)

24h urine test and urine pH

Crystals can start to form with SS levels gt1

Calcium OxalatesPhosphates Most common Radiopaque

Uric Acid Calculi Uric Acid levels Most are radiolucent

Cysteine Calculi Cystinuria Rare and more radiolucent than opaque Resistant to SWL

Staghorn Calculi

Most common stones

Patient with Plaque disease (Randallrsquos Plaque)

Propensity for UTI

Hypercalciuria

Low urine pH

Obesity

gt90 radiolucent SWL of little value Medical therapy

with K-Citrate or Na-

Citrate is mainstay Alkalize the urine UA levels low urine

pH Risk of Gout

Cystinuria

Rare

More radiolucent than opaque

Resistant to SWL

Increased risk of Renal Failure

Branched Stones within the collecting system calices

Mixture of Ammonium phos and calcium carbonate

Untreated results in Severe sepsis and kidney disease

Hx of Calculi

Family Hx of Calculi

Renal Colic ndash Severe Flank Pain

NauseaVomiting - systemic

FeverChills ndash ro Sepsis Lactate Acid Levels

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Describe the risk factors and causes of Renal and Ureteral Calculi

Identify the various types of Renal and Ureteral Calculi

Demonstrate the medical and surgical treatment of Renal and Ureteral Calculi

Highlight the complications related to various Renal Calculi

Discuss the role of PAs in Stone management

Pure causes are unknown

Risk Factors are well defined Hypercalciuria

Hyperparathyroidism

Hypercalcemia

Primary Hyperoxaluria

12 Men 5 Women

Increasing prevalence

1 in 11 people 50 reoccurrence

Composition of stones well known

Causes are still uncertain

Urinary Supersaturating (SS)

24h urine test and urine pH

Crystals can start to form with SS levels gt1

Calcium OxalatesPhosphates Most common Radiopaque

Uric Acid Calculi Uric Acid levels Most are radiolucent

Cysteine Calculi Cystinuria Rare and more radiolucent than opaque Resistant to SWL

Staghorn Calculi

Most common stones

Patient with Plaque disease (Randallrsquos Plaque)

Propensity for UTI

Hypercalciuria

Low urine pH

Obesity

gt90 radiolucent SWL of little value Medical therapy

with K-Citrate or Na-

Citrate is mainstay Alkalize the urine UA levels low urine

pH Risk of Gout

Cystinuria

Rare

More radiolucent than opaque

Resistant to SWL

Increased risk of Renal Failure

Branched Stones within the collecting system calices

Mixture of Ammonium phos and calcium carbonate

Untreated results in Severe sepsis and kidney disease

Hx of Calculi

Family Hx of Calculi

Renal Colic ndash Severe Flank Pain

NauseaVomiting - systemic

FeverChills ndash ro Sepsis Lactate Acid Levels

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Pure causes are unknown

Risk Factors are well defined Hypercalciuria

Hyperparathyroidism

Hypercalcemia

Primary Hyperoxaluria

12 Men 5 Women

Increasing prevalence

1 in 11 people 50 reoccurrence

Composition of stones well known

Causes are still uncertain

Urinary Supersaturating (SS)

24h urine test and urine pH

Crystals can start to form with SS levels gt1

Calcium OxalatesPhosphates Most common Radiopaque

Uric Acid Calculi Uric Acid levels Most are radiolucent

Cysteine Calculi Cystinuria Rare and more radiolucent than opaque Resistant to SWL

Staghorn Calculi

Most common stones

Patient with Plaque disease (Randallrsquos Plaque)

Propensity for UTI

Hypercalciuria

Low urine pH

Obesity

gt90 radiolucent SWL of little value Medical therapy

with K-Citrate or Na-

Citrate is mainstay Alkalize the urine UA levels low urine

pH Risk of Gout

Cystinuria

Rare

More radiolucent than opaque

Resistant to SWL

Increased risk of Renal Failure

Branched Stones within the collecting system calices

Mixture of Ammonium phos and calcium carbonate

Untreated results in Severe sepsis and kidney disease

Hx of Calculi

Family Hx of Calculi

Renal Colic ndash Severe Flank Pain

NauseaVomiting - systemic

FeverChills ndash ro Sepsis Lactate Acid Levels

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

12 Men 5 Women

Increasing prevalence

1 in 11 people 50 reoccurrence

Composition of stones well known

Causes are still uncertain

Urinary Supersaturating (SS)

24h urine test and urine pH

Crystals can start to form with SS levels gt1

Calcium OxalatesPhosphates Most common Radiopaque

Uric Acid Calculi Uric Acid levels Most are radiolucent

Cysteine Calculi Cystinuria Rare and more radiolucent than opaque Resistant to SWL

Staghorn Calculi

Most common stones

Patient with Plaque disease (Randallrsquos Plaque)

Propensity for UTI

Hypercalciuria

Low urine pH

Obesity

gt90 radiolucent SWL of little value Medical therapy

with K-Citrate or Na-

Citrate is mainstay Alkalize the urine UA levels low urine

pH Risk of Gout

Cystinuria

Rare

More radiolucent than opaque

Resistant to SWL

Increased risk of Renal Failure

Branched Stones within the collecting system calices

Mixture of Ammonium phos and calcium carbonate

Untreated results in Severe sepsis and kidney disease

Hx of Calculi

Family Hx of Calculi

Renal Colic ndash Severe Flank Pain

NauseaVomiting - systemic

FeverChills ndash ro Sepsis Lactate Acid Levels

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Calcium OxalatesPhosphates Most common Radiopaque

Uric Acid Calculi Uric Acid levels Most are radiolucent

Cysteine Calculi Cystinuria Rare and more radiolucent than opaque Resistant to SWL

Staghorn Calculi

Most common stones

Patient with Plaque disease (Randallrsquos Plaque)

Propensity for UTI

Hypercalciuria

Low urine pH

Obesity

gt90 radiolucent SWL of little value Medical therapy

with K-Citrate or Na-

Citrate is mainstay Alkalize the urine UA levels low urine

pH Risk of Gout

Cystinuria

Rare

More radiolucent than opaque

Resistant to SWL

Increased risk of Renal Failure

Branched Stones within the collecting system calices

Mixture of Ammonium phos and calcium carbonate

Untreated results in Severe sepsis and kidney disease

Hx of Calculi

Family Hx of Calculi

Renal Colic ndash Severe Flank Pain

NauseaVomiting - systemic

FeverChills ndash ro Sepsis Lactate Acid Levels

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Most common stones

Patient with Plaque disease (Randallrsquos Plaque)

Propensity for UTI

Hypercalciuria

Low urine pH

Obesity

gt90 radiolucent SWL of little value Medical therapy

with K-Citrate or Na-

Citrate is mainstay Alkalize the urine UA levels low urine

pH Risk of Gout

Cystinuria

Rare

More radiolucent than opaque

Resistant to SWL

Increased risk of Renal Failure

Branched Stones within the collecting system calices

Mixture of Ammonium phos and calcium carbonate

Untreated results in Severe sepsis and kidney disease

Hx of Calculi

Family Hx of Calculi

Renal Colic ndash Severe Flank Pain

NauseaVomiting - systemic

FeverChills ndash ro Sepsis Lactate Acid Levels

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

gt90 radiolucent SWL of little value Medical therapy

with K-Citrate or Na-

Citrate is mainstay Alkalize the urine UA levels low urine

pH Risk of Gout

Cystinuria

Rare

More radiolucent than opaque

Resistant to SWL

Increased risk of Renal Failure

Branched Stones within the collecting system calices

Mixture of Ammonium phos and calcium carbonate

Untreated results in Severe sepsis and kidney disease

Hx of Calculi

Family Hx of Calculi

Renal Colic ndash Severe Flank Pain

NauseaVomiting - systemic

FeverChills ndash ro Sepsis Lactate Acid Levels

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Cystinuria

Rare

More radiolucent than opaque

Resistant to SWL

Increased risk of Renal Failure

Branched Stones within the collecting system calices

Mixture of Ammonium phos and calcium carbonate

Untreated results in Severe sepsis and kidney disease

Hx of Calculi

Family Hx of Calculi

Renal Colic ndash Severe Flank Pain

NauseaVomiting - systemic

FeverChills ndash ro Sepsis Lactate Acid Levels

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Branched Stones within the collecting system calices

Mixture of Ammonium phos and calcium carbonate

Untreated results in Severe sepsis and kidney disease

Hx of Calculi

Family Hx of Calculi

Renal Colic ndash Severe Flank Pain

NauseaVomiting - systemic

FeverChills ndash ro Sepsis Lactate Acid Levels

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Hx of Calculi

Family Hx of Calculi

Renal Colic ndash Severe Flank Pain

NauseaVomiting - systemic

FeverChills ndash ro Sepsis Lactate Acid Levels

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Urinary Tract Infections

Appendicitis

Diverticulitis

Acute Back Pain

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

History Detailed Dietary hx is important Kidney stone pain is related to acute obstruction

Physical Flank Tenderness

Ancillary Testing UAUCS Uric Acid Levels Serum Creatinine ndash should be normal Imaging

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

KUB Radiolucent

Radiopaque

RUS Hydronephrosis

Ureteronephrosis

IVP

Abdominal CT scan (non contrast) Gold Standard

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

bull Abdominal CT - Gold standard

Non Contrast

Pyelogram ndash Antegrade vs Retrograde

Cystoscopy

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Goals of treatment Pain relief Emergency Management

Definitive treatment

Stone stratification Stone Location (Renal Proximal mid or distal)

Stone size (lt=5mm gt5mm lt=10mm gt10mm)

Observation and Medical Explusive Therapy

Surgical Endoscopic and Extracorporeal

Percutaneous and Open

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Observation Stones lt = 5mm

No ureteral Obstruction No pain

68 spontaneous expulsion rate

Stones gt 5mm lt 10mm

47 spontaneous expulsion rate

Medical Expulsive Therapy Alpha Blockers ndash 81 (Preferred agent)

Calcium Channel Blockers ndash 71

Dietary Modifications 25liters of water per day

AUA 2007

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Primary surgical treatment of RenalUreteral stones

The only non invasive surgical management of renal and ureteral stones

Approved in 1980

Series of shockwaves delivered through a lithotripter

Success is influenced by stone size location and patient body habitus etc

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

httpswwwyoutubecomwatchfeature=player_detailpageampv=GwQBpp3KiPc

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

First Line surgical therapy

Flexible or rigid scope through the ureter

Basket deployment to capture the stone

100 clearance if successful

Laser to fracture large stone

+- Ureteral stent

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

httpswwwyoutubecomwatchfeature=player_detailpageampv=u9O-kKSxKi0

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

More surgically invasive

Reserved for Complex stones like staghorn

Open or Robotic approach

Stones gt15cm

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Complex management Strategies Requires multiple approach

Goal is Renal Protection

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

httpswwwyoutubecomwatchfeature=player_detailpageampv=BCzxODuF3R8

httpswwwyoutubecomwatchfeature=player_detailpageampv=_Sk4MDsbukg

Pregnancy Renal colic is the most common non OB cause of

pain during pregnancy

Deliver Deliver and then Deliver

Pain Relief

US or limited IVP

Surgery - Ureteral Stenting or PCN

Sepsis Fluids Abx

Surgery

Acute Renal Failure

Medical Assessment and treatment

Counseling and education

Diagnosing and Ancillary testing

Emergent consults and management

Pre op and Post Op management

First Assist ndash Robotic Pyelolitotomy

Cystoscopy and Stent removals

Questions

wwwnatural-homeremediesorg

wwwaafporg

httpswwwstudybluecomnotesnotenrenal-stonesdeck4444591

httpswwwstonediseaseorgkidney-stone-photos

httpwwwcomiterpacom2Fhematuria2520radiologic_studieshtmampbvm

httpwwwwebmdcomkidney-stoneskidney-stone-seen-on-intravenous-pyelogram-ivp

httpmanju-imagingxpertblogspotcom2011_04_01_archivehtml

httpintranettdmueduuadatakafedrainternalendoscop_fpoclasses_studenmedlikptnurology420yearLesson203htm

Medical Assessment and treatment

Counseling and education

Diagnosing and Ancillary testing

Emergent consults and management

Pre op and Post Op management

First Assist ndash Robotic Pyelolitotomy

Cystoscopy and Stent removals

Questions

wwwnatural-homeremediesorg

wwwaafporg

httpswwwstudybluecomnotesnotenrenal-stonesdeck4444591

httpswwwstonediseaseorgkidney-stone-photos

httpwwwcomiterpacom2Fhematuria2520radiologic_studieshtmampbvm

httpwwwwebmdcomkidney-stoneskidney-stone-seen-on-intravenous-pyelogram-ivp

httpmanju-imagingxpertblogspotcom2011_04_01_archivehtml

httpintranettdmueduuadatakafedrainternalendoscop_fpoclasses_studenmedlikptnurology420yearLesson203htm

Questions

wwwnatural-homeremediesorg

wwwaafporg

httpswwwstudybluecomnotesnotenrenal-stonesdeck4444591

httpswwwstonediseaseorgkidney-stone-photos

httpwwwcomiterpacom2Fhematuria2520radiologic_studieshtmampbvm

httpwwwwebmdcomkidney-stoneskidney-stone-seen-on-intravenous-pyelogram-ivp

httpmanju-imagingxpertblogspotcom2011_04_01_archivehtml

httpintranettdmueduuadatakafedrainternalendoscop_fpoclasses_studenmedlikptnurology420yearLesson203htm

wwwnatural-homeremediesorg

wwwaafporg

httpswwwstudybluecomnotesnotenrenal-stonesdeck4444591

httpswwwstonediseaseorgkidney-stone-photos

httpwwwcomiterpacom2Fhematuria2520radiologic_studieshtmampbvm

httpwwwwebmdcomkidney-stoneskidney-stone-seen-on-intravenous-pyelogram-ivp

httpmanju-imagingxpertblogspotcom2011_04_01_archivehtml

httpintranettdmueduuadatakafedrainternalendoscop_fpoclasses_studenmedlikptnurology420yearLesson203htm

httpmanju-imagingxpertblogspotcom2011_04_01_archivehtml

httpintranettdmueduuadatakafedrainternalendoscop_fpoclasses_studenmedlikptnurology420yearLesson203htm

httpwwwmainstreetradiologycomct_scansmsr-cs_urographyhtm

httpswwwauanetorgeducationguidelinesmanagement-kidney-stonescfm

Clin J Am Soc Nephrol 2014 Oct 7 9(10) 1757ndash1763 Distinguishing Characteristics of Idiopathic Calcium Oxalate Kidney Stone Formers with Low Amounts of Randalls Plaque Xiangling Wang Amy E Krambeckdagger

James C Williams JrDagger Xiaojing Tang Andrew D Rule Fang Zhao Eric

Bergstralhsect Zejfa Haskic Samuel Edeh David R Holmes III Loren P Herrera Hernandezpara and John C Lieske

httpurologyjhueduMISESWLphp

httpwwwmedandlifero2Farchive2F113-vol-v-iss-2-april-june-20122Fspecial-articles-vol-v-iss22F292-impact-of-obesity-on-retrograde-ureteroscopic-