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Surgery M4 part 2 > urinary stones > Flashcards

urinary stones Flashcards

1
Q

What are the causes of urinary stones?

A
  • Vitamin A deficiency
  • dehydration -> precipitation of solutes
  • reduction of urinary colloids
  • decreased urinary citrate (keeps calcium in solution in solution form)
  • renal infection -> streptococci
  • urinary stasis & inadequate urinary drainage
  • prolonged immobilization
  • hyperparathyroidism
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2
Q

What are the etiologies of calcium oxalate stones?

A
  • hypercalcemia
  • hyperoxaluria
  • increased intake of ethylene glycol or vitamin C
  • inflammatory bowel disease due to malabsorption

will decrease urine pH
radio-opaque

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3
Q

What are the types of urinary stones?

A
  • CALCIUM OXALATE -> irregular & sharp -> hard & radiodense
  • PHOSPHATE CALCULI -> stag horn calculus -> grows in alkaline urine (Proteus) -> presents with hematuria, urinary infection, or renal failure
  • URIC ACID & URATE CALCULI -> multifaceted -> CT to distinguish them
  • CYSTINE CALCULUS -> cystinuria (congenital) -> grow to form a cast of the collecting system -> radio-opaque & very hard
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4
Q

What is the first indication if bilateral silent calculi?

A

Renal failure

- secondary infection produces symptoms

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5
Q

Dull pain in the renal angle or the hypochondrium or both & radiates to the back, with movement making it worse is diagnostic for?

A

RENAL PAIN

- stretching of kidney capsule

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6
Q

Agonizing colicky pain passing from the loin to groin that usually lasts for 8 hours & causes tachycardia is diagnostic for?

A

URETERIC COLIC

  • stone in ureter or stuck at pelviureteric junction
  • patients vomit from severity of pain
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7
Q

What are the clinical features of urinary stones?

A
  • renal pain or ureteric colic
  • haematuria
  • pyuria -> dangerous when kidney is obstructed -> septicemia can develop quickly
    - > could be caused by stones irritating the urothelium in the absence of infection
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8
Q

What are the clinical features of renal destruction?

A
  • pyonephrosis
  • pyelonephritis
  • hydronephrosis
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9
Q

What are the clinical features of pelvi-ureteric obstruction?

A
  • Renal colic
  • total hematuria
  • hydronephrosis
  • pyelonephritis
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10
Q

What are the clinical features of bladder irritation?

A
  • terminal hematuria
  • frequency
  • suprapubic dull pain made worse by bladder filling
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11
Q

What are the clinical features of vesico-ureteric obstructions?

A
  • Renal colic
  • total hematuria
  • hydronephrosis
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12
Q

What the the clinical features of bladder outflow obstruction?

A
  • acute retention

- terminal hematuria

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13
Q

What will be witnessed on the abdominal examination of a patient with a urinary stone?

A
  • during a ureteric colic attack -> rigidity MAY be present
  • tenderness on gentle deep palpation
  • hydronephrosis or pyonephrosis -> palpable loin swelling (rare)
  • renal punch (percussion over the kidney) -> stabbing pain
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14
Q

How is the KUB film taken & what will it show?

A

Kidney, ureter, bladder x-ray

  • patient must be prepared well -> enema, laxative is given the previous day & patient is asked to fast to reduce bowel gas
  • an opacity relative to urinary tract (on lateral x-ray will be ON or POSTERIOR to vertebral body)
  • calcified mesenteric nodes & opacities within the gut is anterior to vertebral bodies on lateral x-rays
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15
Q

What is the best method of investigation to detect a urinary stone?

A

CT (helical CTU)

- can identify other causes of non-stone flank pain

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16
Q

How should renal colic be managed?

A

PAIN RELIEF
- NSAIDS

HYDRATION

WATCHFUL WAITING

  • if stone is 5mm or less
  • alpha-blockers (ZOSINS)
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17
Q

What are the indications for intervention?

A
  • pain that fails to respond to analgesics
  • associated fever
  • renal function is impaired
  • obstruction unrelieved for 4 weeks
  • personal or occupational reasons
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18
Q

What intervention provides temporary relief of obstruction?

A

surgical intervention

  • INSERTION OF JJ STENT
  • PERCUTANEOUS NEPHROSTOMY TUBE
19
Q

What are the methods used to provide a definitive treatment?

A
  • Extracorporeal shockwaves lithotripsy (ESWL)
  • Ureteroscopy (URS)
  • Percutaneous nephrolithotomy (PCNL)
  • Open surgery
20
Q

What are the indications for ESWL?

A
  • only if stone is in kidney or upper ureter

- stone must be less than 2cm

21
Q

What are the limitations to ESWL?

A
  • may need multiple sessions
  • post ESWL ureteric colic is common -> needs NSAIDS
  • must use antibiotic cover due to fear of infection
22
Q

What are the types of open surgery?

A
  • Pyelolithotomy -> incision directly on stone
  • Nephrolithotomy
  • Partial Nephrectomy -> stone in lower most calyx with infective damage
  • Nephrectomy -> functionless kidney
23
Q

How should bilateral renal stones be treated?

A

Treat kidney with better function first UNLESS

  • the other kidney is more painful
  • pyonephrosis -> urgent decompression
24
Q

What should be done to prevent recurrence of stone?

A
  • drink plenty of water
  • screen urine for infection
  • blood investigations -> serum calcium (hyperparathyroidism)
    - > serum uric acid
    - > urinary urate, calcium & phosphate in 24-hr collection
25
Q

What are the normal ureteric anatomical narrowing that could cause stone impaction?

A 
1- uretero-pelvic junction 
2- crossing the iliac artery 
3- juxtaposition of vas deferens or broad ligament 
4- entering bladder wall 
5- ureteric orifice
26
Q

What are the clinical features of ureteric calculi?

A
  • intermittent attacks
  • agonizing loin pain -> referred to groin, external genitalia, & anterior surface of the thigh
  • when it enters the bladder -> referred to the tip of the penis
27
Q

What features occur when the stone gets impacted?

A
  • consistent dull pain in the iliac fossa

- increased by exercise & lessened by rest

28
Q

What are the manifestations of ureteric obstruction?

A
  • severe renal pain that subsides after a day

- if obstruction persists after 1-2 weeks -> calculus should be removed to avoid pressure atrophy or renal parenchyma

29
Q

What will be observed in an abdominal examination of a patient with a ureteric stone?

A
  • tenderness & some rigidity
  • hematuria (does not rule out appendicitis)
  • patient in severe pain
30
Q

How can we confirm the diagnosis of a patient with a ureteric stone?

A

Spiral CT
IVU while patient has pain -> little or no excretion on the affected side
-> dilation of the ureter down to an obstructing calculus
-> filling defect

31
Q

How should a ureteric calculus be treated?

A
  • NSAIDS (diclofenac & indomethacin)
  • removal of stone (it will likely pass naturally)
  • if it doesnt pass & the patient is not disabled by attacks -> follow progress by x-ray every 6-8 weeks
32
Q

What are the indications for surgical removal of a ureteric calculus?

A
  • repeated attacks of pain & the stone is not moving
  • stone is enlarging
  • complete obstruction of kidney
  • urine is infected
  • stone is too large to pass
33
Q

What are the types of surgical removal of ureteric calculus?

A

ENDOSCOPIC STONE REMOVAL

  • Dormia Basket -> danger of ureteric injury
  • Ureteric meatotomy -> endoscopic incision with a diathermy knife

URETEROSCOPIC STONE REMOVAL
- transuretheral route -> remove impacted stone -> fragmented using electrohydraulic, percussive, or laser lithotripter

PUSH BANG
- stone in the middle of upper part of ureter -> flushed back into kidney -> J-stent secures calculus of kidney for subsequent ESWL

LITHOTRIPSY IN SITU

  • stones fragmented in situ
  • not appropriate IF -> completely obstructed OR the stone has been impacted for a long time

OPEN SURGERY
- ureterolithotomy

34
Q

What is the difference between a primary & secondary bladder stone?

A

Primary

  • develops in sterile urine
  • originates in kidney
Secondary 
occurs in presence of
- infection 
- outflow obstruction 
- impaired bladder emptying 
- foreign body
35
Q

What are the symptoms of bladder stones?

A
  • frequency (initially)
  • sensation of incomplete bladder emptying
  • pain (strangury) -> at the end of micturition with oxalate calculus —> referred to tip of penis or labia majora
  • terminal haematuria -> stone abrading the vascular trigone
  • interruption of urinary stream -> stone blocking internal meatus
  • urinary infection (most common)
36
Q

What should be done for men with bladder outflow obstruction due to a bladder stone?

A

endoscopic resection of the prostate at the same time as the stone removal

37
Q

How should a bladder stone be treated?

A
  • cause of stone should be found & treated
  • treat bladder outflow obstruction
  • litholapaxy -> crush stone in bladder & wash out using catheter
38
Q

what are the methods for non-operative conservative therapy?

A
  • blind lithotirite

- lithotrite with ultrasound probe

39
Q

What are the contraindications to peruretheral litholapaxy?

A
  • urethral stricture -> can’t be dilated sufficiently when a patient is below 10
  • contracted bladder
  • very large stone
40
Q

What should be used to remove the bladder stone if the urethra is too narrow?

A

percutaneous suprapubic litholapaxy

41
Q

What are the etiologies of uric acid stones?

A
  • gout
  • hyperuricemia
  • hyperuricosuria
  • high cell turnover (chemotherapy, leukemia)

radioluscent
decrease the acidity of urine

42
Q

What is the cause of struvite stones?

A
  • UTI with urease-producing bacteria (Proteus miribalis)
43
Q

What is the cause of calcium phosphate stones

A
  • hyperparathyroidism

- type 1 renal tubular acidosis

Surgery M4 part 2 (36 decks)

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