management of urinary calculus

UROLOGY

1. DISCUSS THE MANAGEMENT OF URINARY CALCULUS DR BASHIR YUNUS SURGERY DEPARTMENT A.K.T.H 22/4/14 4/21/2014 1

2. OUTLINE INTRODUCTION ANATOMY EPIDEMIOLOGY RISK FACTOR TYPES AETIOPATHOGENESIS PRESENTATION EMERGENCY ELECTIVE ASYMPTOMATIC MANAGEMENT RESUSITATION HISTORY EXAMINATION DIFFERENTIALS INVESTIGATION TREATMENT FOLLOW-UP PREVENTION PROGNOSIS STONES IN SPECIAL SITUATIONS FUTURE TRENDS 4/21/2014 2

3. INTRODUCTION U rinary calculus or stone along the urinary tract. The 3 rd most common urological disease preceded only by UTI and prostate pathology . Stone can be found anywhere along the genitourinary system, of various sizes with varying presentations. Management of stones have been revolutionized by advancement in technology and it depends on the availability of equipment and expertise. 4/21/2014 3

4. ANATOMY 4/21/2014 4

5. ANATOMY Anatomical narrowings : Ureteropelvic junction Crossing of the iliac artery Juxtaposition of broad ligament or vas deference Entering the bladder wall Ureteric orifice 4/21/2014 5

6. EPIDEMIOLOGY World wide distribution, commoner in developed countries also increasing developing countries. Western Europe -2-3% of population Nigeria incidence 7-34 per 100,000. 4/21/2014 6

7. Nigeria Mshelia , 2005. Maiduguri, M:F 12:1 76.9% calcium stones Ekwere , Calabar , high hospital incidence, 19.1 per 100,000. A ttributed high sea food consumption. Hassan , Zaria, Paediatric population 9.6 per 100,000. 59% congenital anomalies Mbonu , Enugu, M:F 5:1 13 per 100,000 hospital population 80% due to obstruction. 4/21/2014 7

8. NIGERIA S A AJI, S U ALHASSAN, A M MOHAMMAD, SA MASHI. KANO; 2011 M:F 3:1 Peaks at 3 rd decade Predominantly upper tract Loin pain as the commonest symptoms 34.2% 4/21/2014 8

9. RISK FACTORS FAMILY HISTORY : 25% of patient with recurrent calcium calculi have family history DEHYDRATION : increase concentration and reduced solubility of urine constituent. Decrease fluid Intake, increase loss of fluid, hot arid region CLIMATE : hot climate. SEX : commoner in males . Testosterone increase endogenous oxalate production and oxaluria . oestrogen increase urinary citrate conc. Thereby preventing oxalate crystal deposition. 4/21/2014 9

10. RISK FACTORS DIET : excessive intake of food containing purines, oxalate, calcium phosphate . AFFLUENCE STRESS OCCUPATIO N: physicians and other white- collar workers, Catheters. HARD WATER MEDICATIONS- antihypertensive medication triamterene CHANGES IN URINE PH; alkali- ( ca , p), acid- (uric a, cystine ) 4/21/2014 10

11. AETIOLOGY METABOLIC CAUSES hypercalcaemia Primary hyperparathyroidism Prolong immobilization Vitamin D intoxication Milk alkali syndrome Sarcoidosis Ectopic parathyroid hormone secretion – hypernephroma , bronchogenic ca. Enzyme disorders Xanthinuria Primary hyperoxaluria Renal tubular syndromes Cystinuria Renal tubular acidosis 4/21/2014 11

12. AETIOLOGY METABOLIC Hyperuricaemia Idiopathic uric acid lithiasis Gout Myeloproliferative disorders Low urinary output states Protein catabolism Leukemia Cytotoxic chemotherapy 4/21/2014 12

13. AETIOLOGY NON-METABOLIC Obstruction – stasis, infection, stone formation. Infectio n- urea splitting organisms; E coli, proteus , klebsella , Pseudomonas Congenital anomalies ; medullary sponge kidneys, horseshoe kidney 4/21/2014 13

14. PATHOGENESIS Explained by theories NUCLEATION THEORY It state that stone originate from crystals or foreign body immersed in supersaturated urine . MATRIX THEORY It postulate that matrix may act as a nidus for crystal aggregation or as a natural glue to adhere small crystals. CRYSTAL INHIBITION THEORY It claims that calculi form owing to the absence or low concentration of urinary stone inhibitors . 4/21/2014 14

15. PATHOGENESIS INHIBITORS OF CRYSTALLIZATION Magnesium Citrate Pyrophosphate Orthophosphates Nephrocalcin Glycosaminoglycans Mucopolysaccharides Uropontin Urinary peptides Artificial urolithiasis inhibitors Methylene blue Phosphonate ions 4/21/2014 15

16. THEORIES Fix particle theory Randalls plaque -- renal papilla Carr microliths -- lymphatics Theory of mass precipitation intranephronic precipitation Crystallization Precipitation theory 4/21/2014 16

17. TYPES CALCIUM OXALATE 60% PHOSPHATE STONE 30% -forms staghorn cal. CALCIUM PHOSPHATE AMMONIUM MAGNESIUM PHOSPHATE CALCIUM AMMONIUM MAGNESIUM PHOSPHATE(triple phosph ) URIC ACID AND URATE STONES 5-10% More found in bladder than kidneys Related to high standard diet CYSTINE STONE 1-3% May aggregate to form staghorn , recurrence is common 4/21/2014 17

18. TYPES OTHERS XANTHENE – def. of xanthene oxidase INDINAVIR – ARV drug related SILICATE MATRIX TRIAMTERENE STONES All are radiolucent 4/21/2014 18

19. CLINICAL PRESENTATION The clinical presentation of patient with urinary calculi depend mainly on the site of stone size of the stones , unilateral or bilateral stone diseases , presence or absence of associated infection 4/21/2014 19

20. PRESENTATION EMERGENCY ELECTIVE SILENT OR ASYMPTOMATIC COMPLICATIONS 4/21/2014 20

21. EMERGENCY RENAL COLIC It is a sudden acute , i ntense , agonizing , paroxysmal pain which begins in the renal angle, then radiates around the flank towards the bladder, testis in the male or labium majus in the female, or to the anterior or lateral aspects of the thigh . (T12-L2) Patient rolls around as excruciating sharp pain superimposed upon a background of continuous discomfort (peristalsis pushing stone down). It is often associated with shock, sweating and nausea or vomiting . It may last only a few seconds or persist for up t 0 48h. It ends dramatically when the SlOne falls back into the pelvis or into the bladder 4/21/2014 21

22. EMERGENCY ACUTE URINE RETENTION UROSEPSIS CALCULUS ANURIA- 4/21/2014 22

23. ELECTIVE PAIN : a dull or boring, ache in the loin, especially in the costo-vertebral ( renal) angle, due to some obstruction of the pelvis. HAEMATURIA ; usu after strenuous activity FREQUENCY PASSAGE OF STONE IN URINE NON- SPECIFIC ; NAUSEA, VOMITING 4/21/2014 23

24. ASYMTOMATIC They are discovered incidentally during routine investigations such as urinalysis and imaging for other disorders 4/21/2014 24

25. COMPLICATIONS RENAL MASS secondary hydronephrosis squamous cell ca. – prolong irritation Pyeonephrosis Perinephric abscess Renal abscess Xantho granulomatous pyelonephritis CHRONIC RENAL FAILURE PERIURETHRAL ABSCESS/FISTULAE 4/21/2014 25

26. DIFFERENTIALS Non urological Appendicitis Diverticulitis Ectopic pregnancy,salphingitis,tortion of ovarian cyst RupturedAAA biliary colic Urological Pyelonephritis Stricture,tumour,renal infarction Testicular tortion 4/21/2014 26

27. MANAGEMENT Depends on the mode of presentation For emergency, patient is resusitated along side some investigation, before a definative procedure Detail history, examination, and investigation are required for elective or asymtomatic presentation 4/21/2014 27

28. RESUSITATION ACUTE RENAL COLIC PAIN – ANALGESIC- NSAID OR NARCOTICS Diclofenac 100mg 2doses usu suffice in acte attack +/- antiemetic OR Im pethidine 75mg + antiemetic or morphine FLUID Given iv, >3L/day if accompanied with vomiting Otherwise liberal fluid intake 4/21/2014 28

29. RESUSITATION ACUTE URINE RETENTION Small stones near the external meatus can be grasped with a grasper. Stone in the prostetic urethra Instill 2% lidocain jelly(allow for 5min) then push stone into the bladder using urethral catheter subsequent removed endoscopically Stone in the penile urethra External urethrotomy Stone impacted in a fossa navicularis or external meatus meatotomy UROSEPSIS IV Fluid resusitation for correction of hypotension if present iv antibiotics 4/21/2014 29

30. RESUSITATION When acute episode subsides, Plain abdominal xray – 90% of stone Abdominal USS – 10% stone, infected hydronephrosis , solitary obstructed kidney Urine: Urinalysis, urine microscopy; microscopic haematuria 90%, wbc , ph , Urgent U/E Cr- calculus anuria . Patient may require nephrostomy for temporal diversion or relieve of obstruction 4/21/2014 30

31. RESUSITATION INDICATIONS FOR URGENT INTERVENTION WHEN THERE IS STONE OBSTRUCTION ASSOCIATED WITH INFECTION. DECREASE RENAL FUCTION CACULUS ANURIA- BILATRAL OBSTRUCTION, OBSTRUCTED SOLITARY KIDNEY PYEONEPHROSIS 4/21/2014 31

32. ELECTIVE DETAIL HISTORY Risk factors Aetiology Complications PHYSICAL EXAMINATION May not reveal any significant finding Hydronephrosis as renal angle mass Tenderness; lumber or iliac A large vesical stone may be felt on bimanual examination 4/21/2014 32

33. INVESTIGATIONS DIAGNOSTIC PLAIN X-RAY KUB- 90% of stones ABD USS- 10% radiolucent (uric, xanthene) IVU- Degree of obstruction Degree of function Confirms radio- opaque stones Show non opaque stones as filling defect Number of the kidneys Where available, non contrast helical CT scan- gold standard AETIOLOGY Urinalysis-pH, rbc , microscopy- crystal sediments STONE ANALYSIS – for stone passed 24 hr urinary calcium (2.5-7.5mmol/24hrs)or uric acid 1g/, cystine 30-50mg/, oxalate 40mg/ Nitroprusside test: Urinary cystine concentration rarely exceeds 70mg %. 4/21/2014 33

34. BLOOD CHEMISTRY RETROGRAGED PYELOGRAM is indicated if the kidney is nonfunctioning from acute obstruction X-RAY OF SMALL BONES OF THE HAND is taken if hyperparathyroidism is suspected when subperiosteal resorption and cystic areas may be seen CYSTOSCOPY It is necessary for the evaluation of lowcr urinary tract obstruction c.g. prostatic hypertrophy, bladdcr infection and visualization of non-opaque stonc.c;e.g . uric acid stone . 4/21/2014 34

35. TREATMENT OPTIONS CONSERVATIVE SURGICAL URETEROSCOPY PCNL ESWL INTERVENTION DEPENDS ON; SIZE OF STONE SITE OF STONE AVAILABILITY OF TREATMENT ABNORMAL ANATOMY OF THE URINARY TRACT PATIENT CHIOCE 4/21/2014 35

36. CONSERVATIVE Small stones (<5 mm ) If stone size <4mm 80%pass spontaneously 4-6mm 50%pass spontaneously >6mm only 10%pass spontaneously More distal the better Pain controlled Absence of renal failure and sepsis 4/21/2014 36

37. CONSERVATIVE Conservative measures include: 1- Encourage fluid intake ≥ than 3L/day. 2- Analgesia (whether NSAID or centrally acting analgesia). 3- Encourage exercise and movement. 4-↓ salts intake. 5- Alkalanization of urine. Review and ensure stone has passed Absence of pain does not confirm stone expulsion 4/21/2014 37

38. CONSERVATIVE Indications for intervention: Failure of conservative treatment Intractable pain refractory vomiting or refractory haematuria . Obstructing large size stone that affecting the renal function or renal parenchyma . OR Prolonged obstruction Non-progressing calculus(impacted)> 2months Infection Stones >5mm 4/21/2014 38

39. OPEN SURGERY Treat UTI if present before surgery X-ray just before surgery to see position of stone. Surgery is indicated : For obstruction with impaired renal function Obstruction with infection Stone >1cm Stone <1cm with symptoms e.g severe pains, haematuria Starghorn calculi Solitary kidney Bilateral obstruction 4/21/2014 39

40. OPEN SURGERY PRINCIPLES To preserve as much as possible of the functioning renal tissue and to prevent complications. Anacsthcsia (by induction, halothane) may lead to decreased urine output after renal surgery in an severly dehydrated patient . Thus there is no place for hypatcnsive anaesthesia in renal surgery . Special considerations In bilateral kidney stone. operate on the most painful side first then on t he other side. In bilateral kidney stones with one non-functioning ( bad) kidney , operate on the healthy side first then perform nephrectomy on the bad kidney . 4/21/2014 40

41. OPEN SURGERY. ( a) Pyelolithotomy : The renal pelvis is incised and the stone removed from the pelvis or calyx. (b) Nephrolithotomy : An incision is made into the kidney substance to remove large stones.Hemorrhage is often severe . ( c) Partial or total nephrectomy is required for a severely damaged kidney . ( d) Ureterolithotomy : An incision is made in the ureter after it has been exposed and the stone removed through it. 4/21/2014 41

42. APPROACHES TO THE KIDNEY Lumbar  or simple flank incision.  Nagamatsu  incision.  Thoracoabdominal  incision.  Transperitoneal  and retroperitoneal incisions.  4/21/2014 42

43. OPEN SURGERY 4/21/2014 43

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45. EXTRA CORPORIAL SHOCK WAVES ( ESWL): treatment of choice for those patients with renal or upper ureteric stones, size(10-25 mm) and those with failed conservative treatment. There are 2 types of shock waves emitters: supersonic emitters and fine amplitude emitters. Contra indications to ESWL: 1. Pregnancy. 2. Large abdominal aneurysm. 3. Uncorrectable bleeding disorders 4/21/2014 45

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50. ESWL Most stone fragments pass within 2-weeks period. A 3-month follow-up KUB film helps direct the need for additional therapy. Complications Sepsis Hematuria Transient renal dysfunction obstruction 4/21/2014 50

51. PERCUTANEOUS NEPHROLITHOTOMY (PCNL ): Antegrade instrumentation of the upper urinary tract via percutaneous puncture. indications : 1. Big renal stones (≥ 25 mm ) –too large for ESWL 2. Distal obstruction not cause by the stone: as PUJ obstruction. 3. Stone in calyceal diverticulum. 4. Lower pole renal stones where the success of ESWL is low. 5. when there is contra indication for ESWL. 4/21/2014 51

52. Procedure of P.C.N.L:- 1 Anesthesia, - GA,LA,ED cystoscopy ureteral catheter instillation of radiopaque dye to opacify the renal pelvicaliceal system( p.c.s ). 2 The patient should be placed in prone position . 3- Under uss guide , the puncture site : few centimeters inferior and medial to the tip of the 12th rib until it reaches the renal pelvis and guide wire left in place. 4/21/2014 52

53. PCNL 4-Dalitation of the tract done with metal or plastic daliators and nephroscopy sheath passed. 5-Destruction of renal stones done with various lithotripters and removal of the fragments through nephroscopy tract . Advantages: • Stone removal rates between 95-99 (difficult access/complete staghorn 80-85%) • Short hospitalisation (1-3days) • Minimal disability 4/21/2014 53

54. PCNL 4/21/2014 54

55. PCNL 4/21/2014 55

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57. PCNL Various types of lithotripters can be used for destruction and removal of renal stones as electrohydrolic , ultrasonic laser probes lithotripters 4/21/2014 57

58. URETEROSCOPY : Mainly for treatment of ureteric stones especially in the fallowing situations 1- Mid and lower ureteric stones with failure of conservative expectant treatment where ESWL is contraindicated. 2- Upper ureteric stones with failure of conservative and ESWL treatment. 3- Impacted upper ureteric stones where ESWL is contra indicated . 4/21/2014 58

59. URETEROSCOPE A small endoscope, which may be rigid, semirigid , or flexible, is passed into the bladder and up the ureter to directly visualize the stone. directly extracted using a basket or grasper or broken into small pieces using various lithotrites ( eg , laser, ultrasonic, electrohydraulic, ballistic). 4/21/2014 59

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63. Dormia basket 4/21/2014 63

64. TREATMENT OPTIONS FOR BLADDER CALCULI 1.Endoscopic vesico litholapaxy : Cystolitholapaxy allows most stones to be broken and subsequently removed through a cystoscope . By cystoscope with use of various types of lithotripters as mechanical, ultrasonic, electrohydrolic or laser lithotripters. 2. Open vesicolithotomy : It is mainly used for very large vesical stones and in children where transurtheral surgery carry high risk of uretheral stricture. It also indicated where facilities for endoscopic surgery are not present. 4/21/2014 64

65. PREVENTION General measures Hydration: aim at urine output >2L/24hrs Dietary restriction Decrease protein intake Decrease dietary calcium Decrease sodium intake Decrease oxalate intake Avoid excess vitamin c Decrease phosphate Increase dietary fibre 4/21/2014 65

66. PREVENTION Specific measures Thiazide diuretics i.e. for calcium oxalate stones Orthophosphates Sodium cellulose phosphates: this tends to bind to calcium thereby inhibiting the intestinal absorption of calcium Allopurinol:→ decreases the production of uric acid. Citrates e.g. sodium potassium citrate, potassium citrate. Magnesium 4/21/2014 66

67. FOLLOW UP History – symptoms Physical examination Metabolic analysis Assessment of renal function – U/ ECr , USS Ensure preventive measures 4/21/2014 67

68. PROGNOSIS Renal ca l culi may recur especially if preventive measures are not rigorously pursued . 4/21/2014 68

69. STONES IN SPECIAL SITUATION RENAL TRANSPLANTATION Urinary stones are rare . Classic renal colic absent ( Perirenal nerves are severed at the time of renal harvesting ) Presumptive diagnosis of graft rejection –high index of suspicion With radiographic and ultrasonic evaluation is the correct diagnosis made Treatment; 4/21/2014 69

70. PREGNANCY Renal colic is the most common nonobstetric cause of acute abdominal pain during pregnancy Calculi are relatively rare, with an incidence 1:1500 pregnancies.  Caution is taken regarding radiation exposure (especially in the 1 st trimester), medications ,  anesthesia ,  and surgical intervention.  About 90%  of symptomatic calculi present during the 2nd and 3rd trimesters. Investigations ; renal uss and limited abdominal x-rays with appropriate shielding.  Treatment ;Temporal- double-J ureteral stent or a percutaneous nephrostomy tube under local anesthesia . 4/21/2014 70

71. STONES IN SPECIAL SITUATION OBESITY Obesity is a risk factor for the development of urinary calculi.  Surgical bypass procedures can cause hyperoxaluria . Problems: limitation in physical examination, diagnostic and treatment options, misguide incisions, prone positioning on lithotripters Ultrasound examination is hindered by the attenuation of ultrasound beams.  CT, fluoroscopy tables,  and lithotripters all have weight limitations Treatment : open surgery 4/21/2014 71

72. STONES IN SPECIAL SITUATION PEDIATRIC PATIENTS Urinary calculi are unusual in children.  Children born prematurely and given furosemide while in the neonatal ICU are at increased risk of developing urinary stone disease . Possibilties of genitourinay abnormalitie s or inherited genetic disorder such as cystinuria , distal renal tubular acidosis, or primary hyperoxaluria. A full and thorough metabolic evaluation should be undertaken.  Stone analysis is particularly helpful in directing these investigations.  Treatment may be limited by endoscope size.  Preliminary data show no change in renal growth after ESWL. PCNL has become an established treatment. 4/21/2014 72

73. STONES IN SPECIAL SITUATION DYSMORPHIA Severe skeletal dysmorphia Congenital ( spina bifida, myelomeningocele , cerebral palsy) or Acquired ( arthritis, traumatic spinal cord injuries) and concurrent urinary calculi Problems: Positioning for ESWL or percutaneous approaches. eg Calculi on the concave side in a patient with severe scoliosis may eliminate percutaneous puncture access between the rib and the posterosuperior iliac spine . Risks for hypercalciuria Immobilization relative dehydration; inability to drink without resistance 4/21/2014 73

74. FUTURE TRENDS Biodegradable ureteric stents Improved instrumentation Increased use of day-case surgery Greater surgical intervention Flexible ureteroscopy More critical use of ESWL with fewer retreatments 4/21/2014 74

75. CONCLUSION Urinary calculi is of increasing burden in developing Countries with urbanization. There is limitation in the management, d ue to limited resources. Most presentation in our environment are infected. Mainstay of treatment in most developing countries still remain surgery. 4/21/2014 75

76. REFERENCES SMITH’S GENERAL UROLOGY, “ URINARY STONE DISEASE ” 17 TH EDITION, McGraw-Hill 2008 246-275 E.A Badoe ET AL, “ Principles and Practice of surgery including pathology in the tropics ” 4 th edition, Assembly of God Literature Center ltd, 2009. M.A.R Al- Fallouji ; “Postgraduate Surgery the candidate guide”. 2 nd Edition. Rced Educational and Professional Pub. Ltd 1998 Baley and Love’s, “ Short Practice of Surgery ” 25 th edition, Edward Arnold Ltd, 2008 1295-1301 CAMPBELL-WALSH UROLOGY , “Urinary Lithiasis ” 10 th EDITION Saunders, an imprint of Elsevier Inc . 2012. Vol 2; . 4/21/2014 76

77. REFERENCES Aji S A, S Alhassan et al . “ Urinary Stone Disease in Kano, North Western Nigeria ” Nigerian Medical Journal. April - June 2011. Vol. 52 Issue 2 S.A.H Rizvi et al; “ The management of stone disease ” BJU Internation 2002, 89(suppl. 1), 62-68 Turk, T Knoll, et al “ Guidelines on Urolithiasis ” European Association of Urology. 2008 A.STEWART AND A DJOYCE. “Modern management of renal colic” Trends in Urology Gynaecology & Sexual Health May/June 2008 4/21/2014 77