Lecture 22 Nephro-Urolithiasis

Question 1

Nephro-Urolithiasis is most common in what gender group

Answer 1

Men

Question 2

What is the peak age in men

Answer 2

30 years

Question 3

What is the bimodal peak in women

Answer 3

35 years

55 years

Question 4

Name the stone types

Answer 4

Calcium oxalate
Calcium oxalate and phosphate
Triple phosphate
Calcium phosphate
Uric acid
Cystine

Question 5

What is the most common type of stone

Answer 5

Calcium oxalate

Question 6

What type of stone is infective

Answer 6

Triple phosphate

Question 7

What are the symptom and signs of stones

Answer 7

• Renal pain (fixed in loin)
• Ureteric colic (radiating
• to groin)
• Dysuria / haematuria /
• Testicular or vulval pain
• Urinary infection
• Loin tenderness
• Pyrexia

Question 8

What initial tests would you do if you suspected stones in the kidney/urinary tract

Answer 8

• Blood tests - FBC, U&E, Creatinine
• Calcium, Albumin, Urate
• Parathormone- hyperparathyroidism (elevated kidney levels)
• Urine analysis and culture
• 24hr urine collections

Question 9

What imaging techniques would you do if you suspected stones in the kidney/urinary tract

Answer 9

• CT KUB- 3D construction
• Intravenous urogram (IVU) using contrast agent
• Ultrasound

Question 10

Name the indications for surgical treatment

Answer 10

• Obstruction.
• Recurrent gross haematuria.
• Recurrent pain and infection.
• Progressive loss of kidney function.
• Patient occupation

Question 11

Name techniques for surgical treatment of stones in the kidney/UT

Answer 11

• Open surgery (rare)
• Endoscopic surgery
• ESWL
PCNL

Question 12

What are the advantages of open surgery

Answer 12

Single procedure with least recurrence rate

Question 13

What are the disadvantages of open surgery

Answer 13

– Large scar
– Long hospital stay
– General wound complications
– Longer recovery

Question 14

Name indications for one surgery

Answer 14

– Non-functioning infected kidney with large stones necessitating nephrectomy
– Cases which for technical reasons cannot be managed by PCNL or ESWL

Question 15

When would simple, partial or total nephrectomy be used

Answer 15

Non functioning kidney
Stag horn stones
Elderly frail patient with complex stones and normal contralateral kidney

Question 16

Name indications for PCNL

Answer 16

Multiple fragments of stones lining the ureter
PUJ stenosis 
Infundibulum stricture
Calyces diverticulum 
Morbid obesity
Skeletal deformity
ESWL resistant stones
Lack of availability to ESWL

Question 17

What stones are most likely to be resistant to ESWL

Answer 17

Cystine

Question 18

How is percutaneous access guided and what instruments could you use

Answer 18

Guided by US or Xray
• Guide wire
• Retrograde catheter or balloon catheter
• Contrast

Question 19

What are some contraindications for PCNL

Answer 19

• Uncorrected coagulopathy.
• Active Urinary Tract Infection.
• Obesity or unusual body habitus unsuitable for X-ray tables.
• Relative contraindications include small kidneys and severe perirenal fibrosis.

Question 20

Name some local complications of PCNL

Answer 20

• Pseudoaneurysm
• AV fistula
• Pelvic tear
• Ureteral tear
• Stricture of PUJ

Question 21

Name some adjacent organ complications of PCNL

Answer 21

• Bowel injury
• Pneumothorax
• Liver, spleen damage- very rare

Question 22

Name some systemic complications of PCNL

Answer 22

Fever
Sepsis
Myocardial infarction

Question 23

What is the first line of treatment for renal and ureteric calculi <2cm

Answer 23

ESWL

Question 24

What is ESWL ineffective against

Answer 24

Cystine stones

Lower pole stones

Question 25

Indications or open surgery for ureteric stones

Answer 25

No suitable for laparoscopic approach | Failed ESWL or ureteroscopy

Question 26

Indications for Ureteroscopy

Answer 26

* Severe obstruction * Uncontrollable pain * Persistent haematuria * Lack of progression * Failed ESWL * Patient occupation

Question 27

What type or ureteroscope is normally used

Answer 27

Rigid

Question 28

Name minor complications of ureteroscopy

Answer 28

* Haematuria * Fever * Small ureteric perforation * Minor vesico-ureteric reflux

Question 29

Name major complications of ureteroscopy

Answer 29

* Major ureteric perforation * Ureteric avulsion * Ureteral necrosis * Stricture formation

Question 30

What are the symptoms of bladder stones

Answer 30

* Suprapubic / groin / penile pain * Dysuria, frequency, haematuria * Urinary infection (persistent) * Sudden interruption of urinary stream * Usually secondary to outflow obstruction

Question 31

How are bladder stones treated

Answer 31

* Most treated endoscopically | * Larger stones can be treated by open excision