Tuesday Urology Conference 16/12/2014

By Dr. Anas HindawiMGH PGY 3 Urology Resident

• 38 y.o female

• Admitted for :• Left flank pain since 2 months • Recurrent UTI’s since 10 yrs associated with Left

flank discomfort only

• PMH : • HTN • CAD• DM type 2

• PSH :• Elective abortion

• Vitals T: 36 ,P 84 ,BP 110/60

• P.E :

• Chest : Clear GBAE • Abdomen : Soft ,Lax ,no organomegaly ,Left CVA tenderness

• Labs :

• Bun 11 ,Cr 0.6 ,• Electrolytes 143 ,4.2 ,107 ,25 • Hg/Hct 13.3/40.6 ,MCV 85• Neutrophils 65

• U/A turbid amber ,7.4 PH ,1015 SG ,+2 LE ,1-2 Rbc ,numerous Wbc • U/Cx Proteus mirabilis > 100.000 CFU ,Sensitive on Amikacin &

Imipinem and all Beta lactam drugs

Next ?

Ultrasound abdomen

• Normal Right kidney

• Left kidney replaced by multiple stones

Next ?

CT Abdomen & Pelvis

Staghorn Calculi • 75% caused by struvite stones

• A struvite stone is an infectious stone caused by urea-splitting bacteria (Proteus, Pseudomonas , and Klebsiella).

• A struvite stone comprises a mixture of magnesium ammonium phosphate and carbonate apatite.

• Escherichia coli never forms struvite stones since it is unable to manufacture urease to make the urine consistently alkaline

• Untreated staghorn calculus is likely to destroy the kidney and/or cause life- threatening sepsis

• Complete removal of the stone is an important goal in order to :

1. eradicate any causative organisms2. relieve obstruction3. prevent further stone growth and any associated infection4. preserve kidney function

Next ?

Tc99m-MAG3

• Noncontrast CT scanning followed by intravenous contrast CT scanning is obtained most often in the evaluation of urinary stones

• Intravenous urography can clearly delineate the pelvic calyceal anatomy

• Narrow, scarred infundibula indicate the need for percutaneous nephrostomy (PCN)

• Wide, large renal infundibula suggest that ESWL might be adequate If the passageway between the calyces and renal pelvis is open and unrestricted

• Nuclear renography findings are helpful for determining the relative function of the affected kidney.

• Ultrasonography alone is insufficient

• MRI does not help visualize urinary calculi

Next ?

Management of Index Patients

• Inform newly diagnosed patients of the relative benefits and risks associated with each active treatment modality.

• Nonsurgical treatment with antibiotics, urease inhibitors and other supportive measures only, is not a viable alternative except in patients otherwise too ill to tolerate stone removal.

PNL Monotherapy• PNL monotherapy is the treatment of choice

except for patients with extremely large and/or complex stones.

• PNL allows removal of a high volume of stone as well as an accurate assessment of stone-free status.

• PNL results in superior stone-free rates compared to SWL and acceptably low morbidity compared to open surgery.

Combination PNL and SWL • The mainstay of combination therapy is endoscopic removal.

• Percutaneous nephroscopy should be the last part of a combination therapy sequence as it allows for better assessment of stone-free status and a greater chance of achieving this state.

• Total removal of fragments from the collecting system after SWL without subsequent nephroscopy is unlikely.

• While non-contrasted computed tomography is now considered the gold-standard method for determining stone-free status, fragments adjacent to nephrostomy tubes may not be detected with this imaging modality.

SWL Monotherapy• SWL monotherapy is not appropriate for most patients

but may be considered in those with stone burdens of <500 square millimeters and no or minimal dilatation of the renal collecting system.

• If SWL is undertaken, establish adequate drainage of the treated renal unit with either an internalized ureteral stent or percutaneous nephrostomy tube before treatment.

• SWL monotherapy can result in significant postoperative complications, including steinstrasse, renal colic, sepsis and perinephric hematoma.

Open Surgery

• Open surgery (nephrolithotomy by any method) is not appropriate for most patients.

• Stone-free states are similar for PNL-based therapy and open surgery, but PNL-based therapy may result in reduced convalescence, shorter hospitalizations and reduced narcotic requirements.

• Consider open surgery in patients with extremely large staghorn calculi, especially in those with unfavorable collecting-system anatomy and in patients with abnormalities of the body habitus, such as extreme morbid obesity or skeletal abnormalities, that may preclude fluoroscopy and endoscopic therapies.

• Anatrophic nephrolithotomy is usually the preferred operation in such cases.

• Complete removal of all stone material is the goal of any procedure

• the patient should be counseled that multiple interventions may be required

• Use of combination therapy is a reasonable approach to ensure removal of all residual fragments

• the immediate use of adjunctive measures can be considered as well direct irrigation of the collecting system is possible through the nephrostomy tube after PNL

Thank you