Urolithiasis

Dr Ahmad KharroubyUrology Specialist

Urolithiasis (from Greek oucircron-urine and lithos-stone) is the condition where urinary stones are formed or located anywhere in the urinary system

Urolithiasis

Background

Kidney stones Ureteral stones Bladder stones Urethral stones

Urolithiasis

Urolithiasis is a common disease that is estimated to produce medical costs of $21 billion per year in the United States alone

Urolithiasis has been a part of the human condition for millennia and have even been found in Egyptian mummies

Background

Renal colic affects approximately 12 million people each year in USA and accounts for approximately 1 of all hospital admissions

Most active emergency departments (EDs) manage patients with acute renal colic every day

Background

Epidemiology

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia

Hot Climate Dietary habits Hereditary factors

Epidemiology

The lower the economic status the lower the likelihood of renal stones

Most at 20-49 years Peak incidence at 35-45 years Male-to-female ratio of 31

Epidemiology

Chemical types and etiology

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Urolithiasis (from Greek oucircron-urine and lithos-stone) is the condition where urinary stones are formed or located anywhere in the urinary system

Urolithiasis

Background

Kidney stones Ureteral stones Bladder stones Urethral stones

Urolithiasis

Urolithiasis is a common disease that is estimated to produce medical costs of $21 billion per year in the United States alone

Urolithiasis has been a part of the human condition for millennia and have even been found in Egyptian mummies

Background

Renal colic affects approximately 12 million people each year in USA and accounts for approximately 1 of all hospital admissions

Most active emergency departments (EDs) manage patients with acute renal colic every day

Background

Epidemiology

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia

Hot Climate Dietary habits Hereditary factors

Epidemiology

The lower the economic status the lower the likelihood of renal stones

Most at 20-49 years Peak incidence at 35-45 years Male-to-female ratio of 31

Epidemiology

Chemical types and etiology

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Background

Kidney stones Ureteral stones Bladder stones Urethral stones

Urolithiasis

Urolithiasis is a common disease that is estimated to produce medical costs of $21 billion per year in the United States alone

Urolithiasis has been a part of the human condition for millennia and have even been found in Egyptian mummies

Background

Renal colic affects approximately 12 million people each year in USA and accounts for approximately 1 of all hospital admissions

Most active emergency departments (EDs) manage patients with acute renal colic every day

Background

Epidemiology

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia

Hot Climate Dietary habits Hereditary factors

Epidemiology

The lower the economic status the lower the likelihood of renal stones

Most at 20-49 years Peak incidence at 35-45 years Male-to-female ratio of 31

Epidemiology

Chemical types and etiology

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Kidney stones Ureteral stones Bladder stones Urethral stones

Urolithiasis

Urolithiasis is a common disease that is estimated to produce medical costs of $21 billion per year in the United States alone

Urolithiasis has been a part of the human condition for millennia and have even been found in Egyptian mummies

Background

Renal colic affects approximately 12 million people each year in USA and accounts for approximately 1 of all hospital admissions

Most active emergency departments (EDs) manage patients with acute renal colic every day

Background

Epidemiology

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia

Hot Climate Dietary habits Hereditary factors

Epidemiology

The lower the economic status the lower the likelihood of renal stones

Most at 20-49 years Peak incidence at 35-45 years Male-to-female ratio of 31

Epidemiology

Chemical types and etiology

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Urolithiasis is a common disease that is estimated to produce medical costs of $21 billion per year in the United States alone

Urolithiasis has been a part of the human condition for millennia and have even been found in Egyptian mummies

Background

Renal colic affects approximately 12 million people each year in USA and accounts for approximately 1 of all hospital admissions

Most active emergency departments (EDs) manage patients with acute renal colic every day

Background

Epidemiology

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia

Hot Climate Dietary habits Hereditary factors

Epidemiology

The lower the economic status the lower the likelihood of renal stones

Most at 20-49 years Peak incidence at 35-45 years Male-to-female ratio of 31

Epidemiology

Chemical types and etiology

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Renal colic affects approximately 12 million people each year in USA and accounts for approximately 1 of all hospital admissions

Most active emergency departments (EDs) manage patients with acute renal colic every day

Background

Epidemiology

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia

Hot Climate Dietary habits Hereditary factors

Epidemiology

The lower the economic status the lower the likelihood of renal stones

Most at 20-49 years Peak incidence at 35-45 years Male-to-female ratio of 31

Epidemiology

Chemical types and etiology

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Epidemiology

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia

Hot Climate Dietary habits Hereditary factors

Epidemiology

The lower the economic status the lower the likelihood of renal stones

Most at 20-49 years Peak incidence at 35-45 years Male-to-female ratio of 31

Epidemiology

Chemical types and etiology

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Urolithiasis occurs in all parts of the world A lifetime risk

2-5 for Asia 8-15 for the West 20 for the Kingdom of Saudi Arabia

Hot Climate Dietary habits Hereditary factors

Epidemiology

The lower the economic status the lower the likelihood of renal stones

Most at 20-49 years Peak incidence at 35-45 years Male-to-female ratio of 31

Epidemiology

Chemical types and etiology

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

The lower the economic status the lower the likelihood of renal stones

Most at 20-49 years Peak incidence at 35-45 years Male-to-female ratio of 31

Epidemiology

Chemical types and etiology

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Chemical types and etiology

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Four main chemical types Calcium stones Struvite (magnesium ammonium phosphate) stones Uric acid stones Cystine stones

Chemical Types

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Calcium stones account for 75 of Urolithiasis

Radio-opaque Multiple factors

and etiologies Mostly incidental

Calcium stones

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Incidental Hyperparathyroidism Increased gut absorption of calcium Renal calcium leak Renal phosphate leak Hperuricosuria Hperoxaluria Hypocitraturia Hypomagnesuria

Calcium Stone Known etiologies

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Calcium Stone

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Account for 15 of renal calculi Infectous stones Gram-negative rods capable of

splitting urea into ammonium which combines with phosphate and magnesium

More common in females Urine pH is typically greater than 7

Struvite (magnesium ammonium phosphate) stones

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Stag horn stones are non obstructive thus painless

Slowly growing Discovered

incidentally

Struvite (magnesium ammonium phosphate) stones

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Account for 6 of renal calculi Urine pH less than 55

High purine intake eg organ meats legumes

malignancy

25 of patients have gout

Uric acid stones

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Uric Acid Stones

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Uric Acid Stones

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

2 of renal calculi Autosomal recessive trait Intrinsic metabolic defect resulting in

failure of renal tubular reabsorption of Cystine Ornithine Lysine Arginine

Urine becomes supersaturated with cystine with resultant crystal deposition

Cystine stones

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Radio-faint

Cystine Stones

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Prognosis

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

80 pass spontaneously 20 require hospital admission or intervention because

of unrelenting pain inability to retain enteral fluids proximal UTI inability to pass the stone renal failure

Prognosis

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Prognosis

Recurrence rates after an initial episode of ureterolithiasis

14 at 1 year 35 at 5 years 52 at 10 years

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

History

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

History

The presentation is variable

Patients with urinary calculi may report Pain Infection Hematuria Asymptomatic

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Silent Kidney stones

Small nonobstructing stones in the kidneys only occasionally cause symptoms

If present symptoms are usually moderate and easily controlled

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

The passage of stones into the ureter is associated with classic renal colic because of

subsequent acute obstruction proximal urinary tract dilation ureteral spasm

Acute renal colic is probably the most excruciatingly painful event a person can endure

Obstructive ureteral stone

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Classic Renal Colic

Acute onset of severe flank pain radiating to the groin Gross or microscopic hematuria Nausea and vomiting not associated with an acute abdomen in

50

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Staghorn calculi are often relatively asymptomatic

Branched kidney stone occupying the renal pelvis and at least one calyceal system

Manifest as infection and hematuria

Staghorn stone

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Acute renal failure

Asymptomatic bilateral obstruction

Solitary Kidney with obstructive stone

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Location and characteristics of pain from ureteral stones

Depends on the level of obstruction and its degree

ureteropelvic junction pelvic brim ureterovesical junction

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

UPJ Stone

Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Ureteral Stone

Cause abrupt severe colicky pain in the flank and ipsilateral lower abdomen

with radiation to the testicles or the vulvar area Intense nausea with or without vomiting usually is

present

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Upper ureter

Tends to radiate to the flank and lumbar areas

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Mid Ureter Cause pain that radiates anteriorly and caudally Can easily mimic appendicitis on the right or acute

diverticulitis on the left

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Distal Ureter and UVJ stones

Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female

At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis such as

urinary frequency dysuria

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Pain distribution review

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Bladder Stones

Usually asymptomatic and are passed relatively easily during urination

Rarely a patient reports positional urinary retention (obstruction precipitated by standing relieved by recumbency)

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Phases of an attack

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase peak in most patients within 2 hours of onset (30 min to 6 hours)

Constant Phase 1- 4 hours maximum 12 hours

Relief phase 15-3 hours

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Physical exam

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Dramatic costovertebral angle tenderness

unremarkable abdominal evaluation painful testicles but normal-appearing constant body positional movements

(eg writhing pacing) Tachycardia Hypertension Microscopic hematuria

Physical exam

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Diagnosis

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone although confirmatory tests are usually performed

Diagnosis

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Laboratory tests

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

The recommended based on EUA recommendations

Urinary sedimentdipstick test To demonstrate blood cells Serum creatinine level To measure renal function

Labarotary Testing

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

May be helpful CBC in febrile patients Serum electrolyte assessment in vomiting patients 24-Hour urine profile on outpatient basis

Additional Lab Tests

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Imaging studies

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Noncontrast abdominopelvic CT scan The imaging modality of choice for assessment of urinary tract disease especially acute renal colic

IV contrast and delayed images might be required in selected cases

Imaging studies

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Renal ultrasonography Renal stone Hydronephrosis or ureteral dilation Misses 30 of stones

Plain abdominal radiograph (flat plate or KUB) misses 40 of stones

Imaging studies

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Imaging studies

IVP (urography) historically the criterion standard

In rare select situations

Plain renal tomography

Retrograde pyelography

Nuclear renal scanning

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Management

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Emergency Renal Colic

IV access to allow Fluid Analgesics

Paracetamol NSAID Opiod

Antiemetic

In case of infection Urine culture Blood culture accordingly eg febrile Antibiotics

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Approach Considerations

In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis

These include Evident infection with obstruction A solitary functional kidney Bilateral ureteral obstruction Renal failure

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Important

The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection

Pyelonephritis Pyonephrosis Urosepsis

Early recognition and immediate surgical drainage are necessary in these situations

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Approach Considerations

The size of the stone is an important predictor of spontaneous passage

A stone less than 4 mm in diameter has an 80 chance of spontaneous passage this falls to 20 for stones larger than 8 mm in diameter

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Approach Considerations

Hospital admission is clearly necessary when any of the following is present

1048698 Oral analgesics are insufficient to manage the pain 1048698Intractable vommiting 1048698 Ureteral obstruction from a stone occurs in a solitary or

transplanted kidney 1048698Bilateral ureteral obstruction 1048698 Ureteral obstruction from a stone occurs in the presence of

a urinary tract infection (UTI) Fever Sepsis Pyonephrosis

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Approach Considerations

Relative indications to consider for a possible admission include comorbid conditions

diabetes dehydration renal failure immunocompromised state perinephric urine extravasation pregnancy

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Approach Considerations

Most patients with acute renal colic can be treated on an ambulatory basis

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Approach Considerations

Aggressive medical therapy has shown promise in increasing the spontaneous stone passage rate and relieving discomfort while minimizing narcotic usage

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Clinic Follow up

Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home

Arrangements should be made for follow-up with a urologist in 2-3 days

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Active medical expulsive therapy

Paracetamol PRN for pain with or without Codeine NSAID PRN for pain Oral opiod analogue for severe pain Alpha blockers Antiemetic PRN for nausea andor vommiting Prednisone 20 mg twice daily for 6 days

With MET stones 5-8 mm in size often pass especially if located in the distal ureter

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Approach Considerations

An important aspect of medical and preventive therapy is maintaining a good fluid intake and subsequent high urinary volume

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Emergency Advice

Patients should be told to return for fever uncontrolled pain uncontrolled vomiting

Patients should be discharged with a urine strainer and encouraged to submit any recovered calculi to a urologist for chemical analysis

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention

Approach Considerations

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Approach Considerations

Larger stones (ie ge 7 mm) that are unlikely to pass spontaneously require some type of surgical procedure

Such patients require mandatory urology follow up

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Approach Considerations

About 15-20 of patients require invasive intervention eventually as emergency or electively due to

stone size continued obstruction Infection intractable pain

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Indications for Surgery

The primary indications for surgical treatment include Pain Infection Obstruction

Indications for urgent intervention Obstruction complicated by evident infection Obstruction complicated by acute renal failure

Solitary kidney Bilateral obstruction

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Surgical options

Obstruction relief Ureteral stent insertion Percutaneous nephrostomy

Definitive surgical treatment ESWL Ureteroscopy PCNL Open laparoscopic and robotic

pyelo-lithotomy ureterolithotomy cystolithotomy

Open anatrophic nephrolithotomy

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Surgical options

For an obstructed and infected collecting system secondary to stone disease

Emergency surgical relief is required with no contraindications percutaneous nephrostomy for critical patients ureteral stent placement for stable patients

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Surgical options

The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques

Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Surgical options

ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones

The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Ureteral Stent

Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction

Relieves renal colic pain even if the actual stone remains

Dilate the ureter making ureteroscopy and other endoscopic surgical procedures easier to perform later

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Percutaneous nephrostomy

Indicated if stent placement is inadvisable or impossible

In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Extracorporeal shockwave lithotripsy

ESWL the least invasive of the surgical methods of stone removal

Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments

It is especially suitable for stones that are smaller than 2 cm and lodged in

the upper or middle calyx the upper ureter

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Extracorporeal shockwave lithotripsy

The patient under varying degrees of anesthesia The shock head delivers shockwaves developed from an

Electrohydraulic Electromagnetic piezoelectric source

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Ureteroscopy

Ureteroscopic manipulation of a stone is a commonly applied method of stone removal

A small endoscope which may be Rigid Semirigid Flexible

is passed into the bladder and up the ureter to directly visualize the stone

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Ureteroscopy

Flexible ureteroscopy allows tackling of even lower calyceal stones

Stones are fragmented using Swiss lithoclast Laser Ultrasonic lithotripter

Stones are retrieved using a stone basket

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Percutaneous nephrostolithotomy

Percutaneous procedures are generally reserved for large andor complex renal stones and failures from the other 2 modalities

Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Percutaneous nephrostolithotomy

In some cases a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Open Surgery

Open surgery has been used less and less often since the development of the previously mentioned techniques

It now constitutes less than 1 of all interventions

Disadvantages include longer hospitalization longer convalescence increased requirements for blood

transfusion

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Approach Considerations

Metabolic evaluation and treatment at clinic are indicated for patients at greater risk for recurrence including

multiple stones personal or family history of previous stone formation stones at a younger age residual stones after treatment

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Medical Therapy for Stone Disease

Urinary calculi composed predominantly of calcium cannot be dissolved

medical therapy is important in the long-term chemoprophylaxis of further calculus growth or formation

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Medical Therapy for Stone Disease

Uric acid and cystine calculi can be dissolved with medical therapy

Suitable option in patients with uric acid stones who do not require urgent surgical intervention

Is based on alkalization of the urine

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Medical Therapy for Stone Disease

Sodium bicarbonate can be used as the alkalizing agent But potassium citrate is usually preferred because of the

availability of slow-release tablets and the avoidance of a high sodium load

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Medical Therapy for Stone Disease

The dosage of the alkalizing agent should be adjusted to maintain the urinary pH between 65 and 70

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Chemoprophylaxis

Prophylactic therapy might include most importantly augmentation of fluid intake limitation of dietary components addition of stone-formation inhibitors or intestinal calcium binders avoid excessive salt and protein intake

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Chemoprophylaxis

Better to base medical therapy for long-term chemoprophylaxis of urinary calculi on the results of a 24-hour urinalysis for chemical constituents

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Long-Term Monitoring Metabolic evaluation is done by a typical 24-hour urine

determination of urinary volume pH specific gravity Calcium Citrate Magnesium Oxalate Phosphate uric acid

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Long-Term Monitoring

Most common findings are Hypercalciuria Hyperuricosuria Hyperoxaluria Hypocitraturia low urinary volume

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Chemoprophylaxis

Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones allopurinol (300 mg qd) is recommended

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Chemoprophylaxis

Pharmaceuticals that can bind free cystine in the urine D-penicillamine 2-alpha-mercaptopropionyl-glycine

Help reduce stone formation in cystinuria Captopril has been shown to be effective in some trials

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Dietary Measures

In almost all patients in whom stones form an increase in fluid intake and therefore an increase in urine output is recommended

This is likely the single most important aspect of stone prophylaxis

The goal is a total urine volume in 24 hours in excess of 2 liters

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Dietary Measures

The only other general dietary guidelines are to avoid excessive salt and protein intake

Moderation of calcium and oxalate intake is also reasonable

Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders most importantly osteoperosis

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

Thank you

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References

References

bull Main references

bull Medscape article nephrolithiasis by J Stuart Wolf Jr MD FACS updated feb 11 2013

bull Campbell-Walsh Urology 10th edition

bull Smith and Tanaghos General Urology Eighteenth Edition

bull Images used in this presentation are from different web based resources

bull NB The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management

• Urolithiasis
• Slide 2
• Background
• Slide 4
• Slide 6
• Slide 7
• Epidemiology
• Slide 9
• Epidemiology (2)
• Chemical types and etiology
• Chemical Types
• Slide 13
• Slide 14
• Slide 15
• Slide 16
• Slide 17
• Slide 18
• Slide 19
• Slide 20
• Slide 21
• Slide 22
• Prognosis
• Slide 24
• Prognosis (2)
• History
• History (2)
• Silent Kidney stones
• Obstructive ureteral stone
• Classic Renal Colic
• Staghorn stone
• Acute renal failure
• Location and characteristics of pain from ureteral stones
• UPJ Stone
• Ureteral Stone
• Upper ureter
• Mid Ureter
• Distal Ureter and UVJ stones
• Pain distribution review
• Bladder Stones
• Phases of an attack
• Phases of an attack (2)
• Physical exam
• Slide 44
• Diagnosis
• Slide 46
• Laboratory tests
• Slide 48
• Slide 49
• Imaging studies
• Slide 51
• Slide 52
• Imaging studies
• Management
• Emergency Renal Colic
• Approach Considerations
• Important
• Approach Considerations (2)
• Approach Considerations (3)
• Approach Considerations (4)
• Approach Considerations (5)
• Approach Considerations (6)
• Clinic Follow up
• Active medical expulsive therapy
• Approach Considerations (7)
• Emergency Advice
• Approach Considerations (8)
• Approach Considerations (9)
• Approach Considerations (10)
• Indications for Surgery
• Surgical options
• Surgical options (2)
• Surgical options (3)
• Surgical options (4)
• Ureteral Stent
• Percutaneous nephrostomy
• Extracorporeal shockwave lithotripsy
• Extracorporeal shockwave lithotripsy (2)
• Ureteroscopy
• Ureteroscopy (2)
• Percutaneous nephrostolithotomy
• Percutaneous nephrostolithotomy (2)
• Open Surgery
• Approach Considerations (11)
• Medical Therapy for Stone Disease
• Medical Therapy for Stone Disease (2)
• Medical Therapy for Stone Disease (3)
• Medical Therapy for Stone Disease (4)
• Chemoprophylaxis
• Chemoprophylaxis (2)
• Long-Term Monitoring
• Long-Term Monitoring (2)
• Chemoprophylaxis (3)
• Chemoprophylaxis (4)
• Chemoprophylaxis (5)
• Dietary Measures
• Dietary Measures (2)
• Thank you
• References