Renal colic- Investigations and treatment.ppt

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1. RENAL COLIC
INVESTIGATIONS AND TREATMENT
By,
Arvind
200201326

2. INVESTIGATIONS
•Plain X-ray, KUB: To see kidney
shadow, stones (90%—radio-opaque)
•Retrograde pyelography(RPG)-
contrast x-ray if required
•Non contrast CT Scan- Is diagnostic
in ureteric stones

3. INVESTIGATIONS
•Intravenous urogram- used to see renal
functions and for hydronephrosis
•Ultrasound Abdomen- can detect even
radiolucent stone and gives information
about the changes in renal parenchyma

4. INVESTIGATIONS
•Blood: ESR, serum calcium, phosphate, creatinine, blood urea, uric
acid, PTH level.
•Urine: Calcium, urate, cystine if suspected only, pH, specific
gravity.
•Urine culture and sensitivity- In case of infection

5. TREATMENT
•Conservative Management:
•Calculi which are smaller than 0.5cm are likely to pass spontaneously unless
they are impacted.
•Flush therapy—mainly used for lower ureteric stones.
•IV fluids.
•Inj furosemide 60–80 mg IV.
•Anti-inflammatory and antispasmodic agents are given to relieve the pain.
•NSAIDS such as diclofenac and indomethacin have replaced opiates as the
treatment option for renal colic.
•If impacted may lead to symptoms by obstruction of calyx or by acting as a
focus for secondary infection

6. PROCEDURES
•ESWL (Extracorporeal Shock Wave Lithotripsy):
•Piezo-Ceramic or Electromagnetic shock waves are passed to the stone
through water bath or water cushion which acts as a media.
•Dornier Lithotripter is used for fragmenting stones.
•Stone is located and observed through fluoroscope (C-arm) or ultrasound.
Shock waves are triggered to create compressive waves over the stone, to
fragment it. These fragments are flushed out later.

8. •PCNL (Percutaneous Nephrolithotomy).
•Indications: Stones >2.5cm, multiple stones, stones not responding to ESWL
•Initially cystoscopy is done and ureteric stent/catheter is placed and renal
pelvicalyceal system is identified under C-arm guidance.
•Under the guidance of C-arm or U/S, needle puncture is made in the loin
percutaneously. Through kidney, calyx and pelvis are approached. Guidewire
is passed.
•Graduated dilators are passed and so track is widened. Then through that, a
nephroscope is passed.
•After fragmentation, stone is removed using different methods

9. Surgery for renal stones
•Pyelolithotomy: Suitable for stones in extrarenal
pelvis.By loin (posterior subcostal) incision, kidney
is approached.Renal pelvis is opened, the stone is
removed and the pelvis is closed. A drain is placed
and wound is closed.
•Extended pyelolithotomy (Gil-Vernet): In case of
intrarenal pelvis, incision is done on the hilum
between the pelvis and kidney over the renal
sinus, dissection is carried out so as to remove the
stones from pelvis as well as calyces.
•Nephropyelolithotomy: By making incisions both
over the kidney and pelvis, stone/stones are
removed. It is often done in staghorn calculus.

10. •Nephrolithotomy: By placing incision just
behind the most convex surface (Brodel’s
line), stone is removed.
•Partial nephrectomy: Done when there are
multiple stones occupying a pole, usually
lower pole of the kidney or when there is
damage to the calyx, if not removed, may
encourage further stone formation.
•Coagulum pyelolithotomy: Coagulum solution
which contains fibrinogen is poured into the
renal pelvis. It is activated so that it solidifies,
meanwhile entangling the stones in renal
pelvis. This entangled mass is removed en
masse.

11. URETRIC COLIC SURGICAL TREATMENT
Upper third stone:
•ESWL for stone in upper third ureter.
•The stone is pushed into the renal pelvis and then PCNL is done
•URS—Ureterorenoscopic stone removal:
•Through ureteroscope, stone is visualised and often fragmented using
pneumatic bombarder. It is then extracted by ureteroscope. Complications are
perforation of ureter and extraperitoneal leakage of urine, bleeding.
•Open ureterolithotomy through loin incision.

12. Stone in middle third ureter:
•URS
Open ureterolithotomy
•Stone in lower third ureter:
•URS.
•Open ureterolithotomy.
•Using cystoscope under general
anaesthesia, ureteric meatotomy
is done for stones impacted at
the ureteric orifice. It is released
by cutting the orifice at upper
and lateral aspects.
Dormia basketing:
•Indications: single stone, below pelvic brim,
<10mm in size
•Basket is passed into the proximal ureter beyond
the stone and opened. The stone is then pulled out.

13. PREVENTION AND ADVICE
•Hydration is the main method of prevention. Per day 3 to 4 litres of fluid should be
taken.
Diet:
1)Avoid diets rich in calcium oxalate, sodium (natriuresis causes hypercalciuria)
and vitamin C (gets converted into oxalate).
• 2)Increased intake of dietary fibre—binds with intestinal calcium and
decreases the calcium absorption. Sodium cellulose phosphate is used for the
same.
•Allopurinol reduces the uric acid level and so uric acid stone. It also reduces the
oxalate level.
•Diet rich in magnesium makes calcium oxalate less soluble.
• Aluminium gel or ammonium chloride prevents the excessive alkalinity and so
prevents the recurrence of phosphate stones.
• Penicillamine or alpha-mercaptopropinyl-glycine may reduce the recurrence rate of
cystine stones

14. REFERENCE
•Bailey and Love’s Short Practice of Surgery
•SRB’s Manual of Surgery