Urolithiasis

Question 1

What is the relative incidence of stones?

Answer 1

2-3%
More males than females 3:1
Peak age in men is 30 years
Chance of stone recurrence is 50% in 10 years

Question 2

What is the common stone types?

Answer 2

Calcium oxalate most common
Calcium oxalate + phosphate, triple phosphate (infective), calcium phosphate, uric acid and cystine

Question 3

What are the symptoms and signs of stones?

Answer 3

Renal pain (loin), ureteric colic (radiating to groin), dysuria/ haematuria/ testicular or vulva pain, urinary infection, loin tenderness and pyrexia

Question 4

What investigations are done fore stones?

Answer 4

Blood tests - FBC, U+Es and creatinine
Calcium, albumin and urate
PTH
Urine analysis and culture
24hr urine collection

Question 5

What radiology is used to investigate stones?

Answer 5

KUB - kidney, bladder and ureter
US
IVU
CT-KUB/ Urogram

Question 6

What are the indications for surgical treatment?

Answer 6

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

Question 7

What are the techniques for surgical treatment?

Answer 7

Open surgery (very rare)
Endoscopic surgery
ESWL

Question 8

What is the advantages and disadvantages for open surgery for renal stone treatment?

Answer 8

Advantage - single procedure with least recurrence route
Disadvantage - large scar, long hospital stay, general wound complications and longer recovery

Question 9

What are the indications for open surgery?

Answer 9

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

Question 10

When is a simple and total nephrectomy used?

Answer 10

Non-functioning kidney with large staghorn stones or elderly frail patients with complex stones and normal contralateral kidney

Question 11

What are the specific indications for Percutaneous nephrolithotomy (PCNL)?

Answer 11

Large stone burden, associated PUJ stenosis, infundibular stricture, calyceal diverticulum, morbid obesity or skeletal deformity, ESWL resistant stones and lack of ESWL availability

Question 12

What does a PCNL include?

Answer 12

Guide wire
Retrograde catheter or balloon catheter
Contrast

Question 13

How is a percutaneous abscess treated?

Answer 13

Renal puncture
Guided by US or X-ray

Question 14

What are some contraindications for PCNL?

Answer 14

Uncorrected coagulopathy, active UTI, obesity or unusual body habitus unsuitable for X-ray tables, small kidneys and severe perirenal fibrosis

Question 15

What are some complications of PCNL?

Answer 15

Local - pseudoaneurysm or AV fistula and UT injury (pelvic tear, ureteral tear and stricture)
Injury to adjacent organs
Systemic - fever, sepsis and MI

Question 16

Explain extracorporeal shock wave lithotripsy (ESWL)

Answer 16

Simple stones which are too large to pass through - shock waves crush stones
Smaller pieces pass out of body in urine

Question 17

When are ESWL used in treatment?

Answer 17

Commonly used for renal and ureteric calculi as first line treatment
Newer generation lithotripters cause less pain
Can be repeated as often as required

Question 18

When is ESWL ineffective in treatment?

Answer 18

> 2cm stones and lower pole stones
Ineffective for treating cystine stones
If not effective after 2 treatments then further treatment is not justified

Question 19

What are the indications for open ureterolithotomy?

Answer 19

Not suitable for laparoscopic approach
Failed ESWL or ureteroscopy

Question 20

What are the indications for ureteroscopy?

Answer 20

Severe obstruction, uncontrolled pain, persistent haematuria, lack of progression, failed ESWL and patient occupation

Question 21

What instrument is used for treating lower ureteric stones?

Answer 21

Rigid ureteroscope

Question 22

What is used for surgery for ureteric/ renal stones?

Answer 22

Flexible ureteroscopes
Flexible lithoclast
Holmium laser

Question 23

What are some complications of ureteroscopy?

Answer 23

Minor - haematuria, fever, small ureteric perforation and minor ureteric reflux
Major - minor ureteric perforation, ureteric avulsion, ureteral necrosis and stricture formation

Question 24

What are the symptoms for bladder stones?

Answer 24

Suprapubic, groin or penile pain, dysuria, frequency, haematuria, UTI persistent, sudden interruption of urine stream and strangury

Question 25

How are most bladder stones treated?

Answer 25

Endoscopically
Larger can be treated by open excision