Renal Tract Stones Angelika Na

Renal tract stones  10% of Caucasian men by age 70  Recurrence  10% in 1 year, 50% in 10 year  Risk factors  Age  Male, genetics (RTA, cystinuria)  Summer  Water intake  Diet  Occupation

Renal tract stones  Composition  Calcium oxalate (85% of all renal calculi)  HyperCa eg. hyperPTH, Paget’s dx  Uric acid (5-10%)  Gout, myeloproliferative disorder  Calcium phosphate + calcium oxalate (10%)  RTA  Calcium phosphate (rare)  Struvite (infection stones %)  Cystine (1%)  Cystinuria

Renal tract stones  XR  Radio-opaque  Calcium phosphate, calcium oxalate  Radiolucent  Relative - cystine (sulphur), struvite  Complete - uric acid, triamterene, xanthine, indinavir  Size & shape  Staghorn calculi

Kidney stones  Pain, haematuria  UTIs (staghorn, struvite)  Pyonephrosis, perinephric abscess, septic, pyelonephritis  Flank pain

Kidney stones - Mx  Watchful waiting  15 mm (30%) will require intervention  ESWL  2 cm (50%) stone free rates.  Flexible ureteroscopy + laser  2 cm (50%); 10% pt require >2tx  PCNL + lithotripsy  80-90% stone free rates.  Open surgery (nephrolithotomy)  Medical mx

Ureteric stones - Clinical  Renal colic - loin to groin  Uncomfortable, doubled-up with pain, n&v  Fever - BC, IV fluids + Abx, nephrostomy  Pregnancy test  Dipstick + MSU  FBE, UEC, Ca, Uric acid

Differential Diagnosis  AAA  Pyelonephritis  Appendicitis  Ovarian pathology  Biliary pathology

Ureteric stones - Radiology  CT KUB  XR KUB -? radioopaque  (IVP)  MR KUB

XR KUB

CT KUB

Ureteric stones - Mx acute  Analgesia - NSAID, opiate  Fluid  Watchful waiting - stone size  <4 mm - 90% pass spontaneously  4-6 mm - 50%  >6 mm - 20%  Medical mx - tamsulosin

Ureteric stones - Surgical mx  Indications  Pain, bacteriuria, fever, impaired Cr, prolonged unrelieved obstruction, social  Solitary kidney, bilateral stones  Temporary relief of the obstruction  Percutaneous nephrostomy  JJ stent - SE: bladder irritation

Ureteric stones - Surgical mx  Definitive mx  (position of stones)  Ureteroscopy  ESWL (  JJ stent)  PCNL  Ureterolithotomy (open, lap)  Percutaneous antegrade ureteroscopy

Bladder stones  Composition  Struvite (infection), uric acid  Age  Men > 50yo, BPH  Long term IDC / SPC  Children - low phosphate diet  Clinical  Asymptomatic (sc patients) - XR, US  Haematuria, urgency, UTIs, LUTS  Mx  Cystolitholapaxy (endoscopic, open)

Renal tract stones  Treat underlying cause -Hyperparathyroidism - parathyroidectomy -Hyperuricosuria - allopurinol + urine alkalinisation -Homocysteinuria - D-penicillamine  Prevention  Fluid intake  Calcium  Proteins  Wine  Oxalate