flank pain: colic/wave-like, sharp/severe (radiation to abdomen, testicles/labia secondary to obstruction Hematuria: gross or microscopic blood GI: N/V asymptomatic LUTS: urgency/frequency/dysuria/pressue

fluids, antiemetics, pain control surviellance: small non-obstructing renal calculi dissolution therapy: uric acid stone--> urinary alkalinization medical expulsive therapy surgical intervention

Urolithiasis Flashcards by Addie Agboola

Composition of stones

calcium oxalate (most common)
calcium phosphate
uric acid
struvite/ triple phosphate
cystine
other

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most common stone type
mutiple etiologies, dehydration most common, forms in a wide range pH, radio-opaque, not dissolvable

calcium oxalate

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dehydration (MC), hyperuricosuria
forms in ACIDIC URINE (pH < 6)
radiolucent
dissolves with urinary alkalinization

Uric acid

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etio: Metabolic conditions such a renal tubular acidosis, migraines, medications

forms in ALKALINE URINE
Radio-opaque

Calcium phosphate

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struvite and triple phosphate

Etio: UTI (MC)- bacteria produce ammonia that builds up in the urine
forms in ALKALINE urine
radio-opaque
dissolves with urinary acidification

Magnesium ammonium phosphate

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etio: Cystinuria (hereditary genetic disorder)
typically form stones starting in childhood
cystine is a derivative of the amino acid cysteine
forms in ACIDIC urine
radio-opaque
dissolves with urinary alkalinization

cystine

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etio: laxative abuse, UTI radioluscent

ammonium acid urate

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etio: precipitated drug (ex: indinavir/HIV antivirals)

radiolucent & NOT visible on non-con CT

protease inhibitor stones

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etiologies and risk factors for stones

anatomic- obstruction/stasis
urine composition- pH, hypercalcicuria, hypocitrauria, hyperoxaluria, hyperuricosuria, hypomagnesiuria
low urine volume (MC)
diet: sodium, low fiber, high oxalate, carbonated drinks
Hypokalemia
disease states- obesity, DM, HTN, gout, metabolic acidosis etc
UTI
sedentary lifestyle
medications

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symptoms of stones

flank pain: colic/wave-like, sharp/severe (radiation to abdomen, testicles/labia
secondary to obstruction
Hematuria: gross or microscopic blood
GI: N/V
asymptomatic
LUTS: urgency/frequency/dysuria/pressue

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obstructive vs non-obstructive stones

obstructing stones typically cause symptoms secondary to hydronephrosis (celiac ganglion compression)
non-obstructing stones are usually asymptomatic, incidentally notes
can have intermittent obstruction–> colic

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presence of fluid in the kidneys as a result of obstruction
obstruction can be anywhere along urinary tract (meatus to kidney)
can be silent or symptomatic
obstruction can be from a stone (MC), strictures, BOO, BPH, extraureteral compression (think LAD/malignancy) trauma, edema, congenital anomalies, UPJ, blood clot, reflux

hydronephrosis

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Complications of hydronephrosis?

UTI, pyelonephritis
urosepsis
renal atrophy
renal insufficiency/failure
urolithiasis
HTN
renal rupture–> peritonitis

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labs to order for stones?

CBC
BPM
UA
Urine gram stain and C&s
pregnancy test
Mg
PO4
uric acid
PTH
TSH
24h urine stone
calculus analysis

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treatment of stones?

fluids, antiemetics, pain control
surviellance: small non-obstructing renal calculi
dissolution therapy: uric acid stone–> urinary alkalinization
medical expulsive therapy
surgical intervention

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trial of spontaneous passage
hydration, strainer, pain control
alpha blocker, corticosteroids
follow up imaging
appropriate: passable stones, good pain control, no infection, appropriate renal function

Medical expulsive therapy

historically done in tub bath
now done with gel pad under lower body & fluoroscopy
US waves utilized to break up stone +/- stenting
contraindications- pregnancy, coagulopathy, UTI, renal artery calcifications, AAA, radiolucent stones
stone favorable parameters: stone size * location, STSD, HUD

ESWL (extracorporeal shockwave lithotripsy)

complications of ESWL

hematoma
skin ecchymosis
UTI
Pain
Steinstrasse (stone street)
lower stone clearance rate

rigid and flexible
option for stone basketing
disadvantage- need for ureteral stent
good option for failed ESWL or non- ESWL candidate
cystolitholapaxy
complications- ureteral perforation, stricture

Ureteroscopy with laser lithotripsy

Ureteral stone particularly distal ones

Rigid ureteroscopy

Failed ESWL
Renal stones < 2cm
complex anatomy
proximal ureteral stone

flexible ureteroscopy

removes renal calculi from the kidney through percutaneous access from back into the kidney
small hole for large stones? larger stones are laser fragmented before removed
disadvantages: 2-3 day admission, stent and/or nephrostomy tube

Percutaneous nephrolithotomy (PCNL)

Large stones > 2.5cm
failed ESWL
complex anatomic cases
staghorn stones

PCNL

complications of PCNL?

infection
pneumo/hemothorax
injury
extravasation of urine
rare- bowel injury

indications of emergent treatment

* Obstructing stone + infection * bilateral obstruction * solitary kidney * refractory pain * inability to tolerate oral intake d/t NV * goal is to drain the system: Stent & run, nephrostomy tube

can be placed with ESWL, URS, PCNL and in the setting of infection, ureteral injury or ureteral surgery

ureteral stents

prevention of stones?

complete evaluation * 24 hour urine for creatinine, Ca, Mg, Citrate, uric acid, oxalate * serum labs * dietary assesment * assess history for risk factors Dietary managment medical management

what should you know about first time stone formers?

* 50% recurrence within 5-10 years * recurrent stones can lead to renal impairment, infections, pain, multiple ER visits, surgeries

non-medication managment of stones?

* avoidance of stone-provoking drugs * weight loss in the obese * high fluid intake * dietary oxalate restriction * dietary sodium restriction * limit animal protein excess "fleshy foods" * low purine diet- uric acid * avoid extremes of calcium intake

medical management of hypercalciuria?

Thiazide Diuretics * Decrease urinary calcium & correct acidosis * increases reabsorption of calcium in the proximal & distal tubules * inhibits sodium reabsorption in the distal tubule * monitor for hypokalemia

medical management of hypcitrauria?

Potassium citrate * urinary alkalinizer, increases urinary citrate goal pH > 6/5 * monitor for hyperkalemia (sodium bicarbonate, baking soda)

medical management of hyperuricosuria?

Allopurinol * decreases urinary uric acid * works even if normal serum uric acid

medical mangement of cytinuria?

Thiola * forms bond with cysteine to increase its urine solubility