This document summarizes investigations and management of urolithiasis or kidney stones. It discusses basic laboratory tests on urine and blood to identify stones, as well as various imaging techniques like KUB X-rays, ultrasounds, IVUs and CTUs. Management options are outlined depending on stone size and location, including observation, chemolysis, shockwave lithotripsy, ureteroscopic lithotripsy, percutaneous procedures, and open surgery. The document emphasizes the importance of preventing recurrent stones through lifestyle changes, medications, and treating underlying metabolic issues.
8. Imaging: KUB Ultrasound
• Sensitivity to detect renal calculi ~95% (complement KUBXR)
• Very sensitive to detect obstruction and radioluscent stone
• Non-invasive
• May miss small stone (<5mm) and ureteral stone
• Particularly important in pregnant women
10. Imaging: IVU
• Provide anatomical and functional informations
• Size and location of the stone
• Presence and severity of obstructions
• Renal and ureteral abnormalities
11. Imaging: IVU
Indications
• Urolithiasis/nephrolithiasis
• Suspected urinary tract pathology
• Repeated infections
• Idiopathic hematuria
• Investigate uncontrolled HPT in young
adults
• Renal colic
• Trauma
• VUR
Contraindications
• General contraindications to water
soluble contrast agents
• Hepatorenal syndrome
• Thyrotoxicosis
• Pregnancy (allow 28 days from childbirth)
• Blood urea raised about 12mmol/L
18. Imaging: CT-urography
• Evaluate kidney, ureter and bladder
• Not require any bowel preparations
• Faster than IVU
• Radiation dose higher than IVU
- Use CT protocol for patient under age 40
19. Imaging: CT-Urography
Indications
• Urinary calculi
• Hematuria
• Flank and abdominal pain
• Renal and urothelial
neoplasm
• Congenital anomalies of
kidney and ureter
Contraindications
• Renal insufficiency
• Prior severe reaction
• pregnancy
21. Radionuclide study : DTPA
• Diethylene triamine pentaacetic acid
• Evaluate obstruction, perfusion, GFR quantifications
• Adv: relative split function of both kidney
26. Initial Management
• IV access for fluid, analgesics and antiemetics
• Analgesics:
• NSAIDS (Voltaren)
• avoid Morphine – provoke/ prolong ureteric spasm and pain
• Antibiotics : IV cefuroxime 1.5mg TDS if infection
• Imaging
27. Evidence of Obstruction or Infections?
• Complete obstruction of ureter (IVU, CTU)
• Infection above the obstructing stone
• Aim: prevent renal damage
• Options:
• Percutaneous nephrostomy
• Ureteral stent placement
• Endoscopic removal of stone
28. Ureteral Stent Placement
• Relieve obstruction and infection of ureter
• Primary choice due to less invasiveness and less bleeding risk
• Allow urine drainage and improve renal colic
• Cx: blocked, kinked, dislodged and infected
29. Percutaneous Nephrostomy Tube
• Choice of treatment if stent cannot be placed percutaneously or require
future percutaneous treatment of stone burden
• Temporary urinary diversion
• Contraindicated:
• Bleeding diasthesis
• Uncooperative patient
• Severe hyperkalemia (>7mEq/L)
• Complications
• Bleeding
• Sepsis
• Injury to other organs
31. No evidence of obstruction or infection
Observation Surgical
- stone <5mm
- Asymptomatic patients
• persistent, recurrent or severe pain
• Obstruction or infection
• Risk of pyonephrosis and urosepsis
• Solitary kidney
• Bilateral obstruction
32. No evidence of Obstruction or Infection
Location <5mm 5-10mm 1-2cm >2cm
Urethra Pass
spontaneously
Open
Vesicolithotripsy
Bladder Pass
spontaneously
Transurethral
Cystolitholapaxy
Ureter MET URS
ESWL
MET
URS
ESWL
URS
Open/
Laparoscopic
uretherolithotomy
Kidney MET ESWL
RIRS
MET
ESWL
RIRS
PCNL
# At any size, chemolysis is important
33. Chemolysis
Stone Chemolysis
Calcium -least amenable of stone
- Strong acid for stone to dissolve (not safe for human)
Struvite stone - Soluble in acid condition
- Rx: Acetohydroxamic acid (AHA) 250 mg TDS (irreversible
urease inhibitor)
- AE: hemolytic anemia, neurosensory deficit and
thrombophlebitis
Uric acid stone -soluble in alkaline condition
- Rx: Na bicarbonate 650mg-1g TDS/QID (urine alkalinization)
Acetazolamide 250-500mg ON (carbonic anhydrase inhibitor)
Cystine stone -soluble in alkaline condition
-Rx: (D-penicillamine 1-2mg/d OR a-mercaptopropionylglycine
OR acetylcysteine ) + Na bicarbonate
34. MET
• Nephrolithiasis: 3-8 mm
• Likelihood of 65% for stone passage
• Conservative management: oral/iV hydration + analgesics, +
medications that promote stone passage
• Rx: Tamsulosin (a-blocker), Nifedipine
• Relaxes the intramural smooth muscle of ureter urine and
stone passage
• Controversial: safety?? – use as off label
35. Bladder stone
• Options
• Transurethral cystolitholapaxy
• Percutaneous suprapubic cystolitholapaxy (paeds)
• Method
• Cystoscope fragment stone stone remove via cystoscope
36. Extracorporeal Shockwave Lithotripsy
(ESWL)
• Underwater energy wave shatter stone into passable fragments
• Fragments pass down through ureter ureteric colic (diclofenac)
• Indications
• stone <2cm
• Upper and middle ureter; kidney
• Contraindications
• Pregnant mother
• Untreatable bleeding diasthesis
• Impacted stone
• Ureteral obstruction distal to the stone
37. • Complications
• Ureteric obstructions (bulky fragments) ureteral stent prior to
ESWL
• Urosepsis prophylactic antibiotic prior to ESWL (currently not
needed)
38. Uteroscopic Lithotripsy (URS)
• Endoscopic: pass ureteroscope fragment stone stone pass /
wire basket to fish out stone
• Advantage: remove hard stone, ureteral dilatation
• Can be performed in patient with bleeding diasthesis
• Contraindications: untreated UTI
• Complications (rare)
• Hematuria
• Ureter perforation
• Stone migration
• First choice for ureteral stone >10mm
• First choice for distal ureteral stone
<10mm other than ESWL
39. Open/ Laparoscopic Urolithotomy
• Indications
• Complex stone burden : multiple, impacted ureteric stone
• Treatment failure
• Morbid obesity
• Skeletal abnormalities
• Plan for partial nephrectomy and nephrectomy
• Patient’s choice
• Stone in ectopic kidney
40. Retrograde Intrarenal Surgery (RIRS)
• Indications
• Failed ESWL
• Lower calyx stone
• Concomittant ureteric and kidney stone
• Bleeding disorders, unfit for anesthesia
• Gross obesity
• Need for complete stone removal . Eg: pilot
• Complications: rare
• Guide wire pass and ureteral
dilate flexible ureteronoscope
irrigate lithotripsy
stone retrieve with basket
ureteral stent placement
41. Percutaneous Nephrostolithotomy (PCNL)
• Indications
• Renal stone >2cm
• Staghorn calculi
• Failed / contraindicated for ESWL
• Contraindications
• Uncorrected bleeding diasthesis
• Untreated UTI
• Complications
• Perforation of collecting systems
• Perforation of colon or pleural cavity
• Hemorrhage from punctured renal parenchyma
Placement of hollow needle
into collecting system
fragmented remove
stone/ allow drainage