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Urolithiasis : Etiology, Symptoms, and Management

Urolithiasis : Etiology, Symptoms, and Management. Suzanne Biehn Stewart, MD Division of Urology Duke University Medical Center. Overview. Urinary stones have plagued humans since the beginning of recorded history Initial stones uncovered in mummified remains of Egyptians ~7,000 years ago

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Urolithiasis : Etiology, Symptoms, and Management

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  1. Urolithiasis: Etiology, Symptoms, and Management Suzanne Biehn Stewart, MD Division of Urology Duke University Medical Center

  2. Overview Urinary stones have plagued humans since the beginning of recorded history Initial stones uncovered in mummified remains of Egyptians ~7,000 years ago Overtime, we have made drastic improvements in our understanding of stone formation and treatment strategies Babayan RK et al. “Urinary Calculi and Endourology,” Handbook of Urology, 3rd ed. 2004

  3. Learning Goals Risk factors for stone disease Economic implications Various types of stones Causes of stone development Common symptomatology Acute Evaluation tools Differentiate patients that need immediate vs delayed intervention Various options for treatment Treatment complications Recommended follow-up

  4. Epidemiology—1 Overall 1-3% of adults are affected in industrialized nations In the US, highest prevalence is in the Southeast (the Stone Belt) Courtesy of Preminger GM.

  5. Epidemiology—2 Natural History and Risk Factors Peak incidence age:30-60 years Race:4-5x more common in whites than blacks Family history: 3 fold risk Body size: risk with weight

  6. Epidemiology—3 Changing Trends • Historically…. • Stones were 3x more common in males than females • Currently…. • Males are only 1.3x more likely to form stones than females (2002) • Secondary to changes in diet, lifestyle and increased obesity in females Scales et al. 2005

  7. Epidemiology—4 Changing Trends in Hospital Discharges for Renal Calculus by Gender 12.2%, p = .002 21.0%, p = 0.001 Scales et al. 2005

  8. Epidemiology—5 Stones are Common… • Annual incidence in males = 1% • Lifetime risk in white males = 20% • Life long disease • Risk of recurrence after first stone: • Year 1 10 - 15% • Year 5 50 - 60% • Year 10 70 – 80% • Average of 9 yrs intervening between episodes And Costly… • In US, stone disease accounts for > 400,000 hospitalizations annually

  9. Epidemiology—6 Economic Implications • In 1993, inpatient and outpatient costs estimated$2.39 Billion/year1 • By 2050, its estimated that there will be 1.6-2.2 million extra stone cases in the US secondary to global warming • Leading to an additional healthcare cost of 0.9—1.3 billion/year2 1Thompson et al. 1995; 2Pearle M. 2o08

  10. Etiology—1 • Stone development is complex and multifactorial • Causes are specific to the type of stone formed (ie stone composition) • > 90% of patients a metabolic etiology can be found • General pathophysiology principals: • Supersaturation: Urine becomes oversaturated with a type of solute, which then comes out of solution (crystallization) • Dehydration, urinary obstruction and stasis • Inhibitor deficiency: Urine normally has substances which block crystallization (ie citrate and magnesium) • Dietary deficiencies

  11. Etiology—2 Influential Factors in Stone Formation • Dehydration • Major player in majority of stones • Geographic location: high temperatures • Anatomic obstruction and urinary stasis • Metabolic/Urine composition • Urinary pH • Increased stone forming substances (calcium, oxalate, uric acide) • Decreased stone inhibiting substances (citrate and magnesium) • Diet • Urinary tract infection • Urease producing organisms: Proteus, Klebsiella, Pseudomonas, Serratia

  12. Etiology—2 Influential Factors in Stone Formation • Sedentary lifestyle/immobilization • Increased bone reabsorption increases urinary calcium • Disease states • Sarcoidosis • Hyperparathyrodism • Inflammatory bowel disease • Chronic diarrhea • s/p Gastric bypass • Cystinuria • Gout • Medications • HIV Protease inhibitors: Indinavir and Nelfinavir

  13. Etiology—2 Types of Stones • Calcium-based: ~80% all stones • Calcium oxalate • Most common stone formed in industralized nations • Most common type of bladder stone • Radio-opaque • Very difficult to dissolve • Dehydration = common influential factor Calcium oxalate Dihydrate crystals Monohydrate crystals

  14. Etiology—3 Types of Stones • Calcium-based: • Calcium phosphate • ~10% of calcium stones • Influential factors: Hyperparathyroidism, UTI, dehydration • Non-calcium-based • Uric Acid (8%) • In pure form radiolucent • Form in acidic urine (pH < 6.0) • Dissolves with alkalization of urine Calcium phosphate crystals

  15. Etiology—4 Types of Stones • Non-calcium-based • Uric Acid (8%) • Dehydration = common influential factor • Patients usually have normal plasma and urine uric acid levels Uric acid stone Uric acid crystals

  16. Etiology—5 Types of Stones • Non-calcium-based • Struvite (10%) • Often called “infectious stones” • Associated with UTI • Majority of staghorncalculi are struvite composition • Form in alkaline urine • Radio-opaque Struvite crystal Struvite stone

  17. Etiology—6 Types of Stones • Non-calcium-based • Cystine (1%) • Caused by cystinuria—homozygous recessive disorder • Forms in acidic urine • Dissolves with urinary alkalization • Radio-opaque • Resistant to Extracorporeal Shock Wave Lithotripsy (ESWL) • May form staghorns Cystine crystal Cystine stone

  18. Etiology—7 Anatomic Locations for Stone Formation Can form and be found anywhere along the urinary tract • Kidney • Stone nidus typically starts to develop • Ureter • Stone nidus can form here secondary: • Obstruction—i.e. stricture • Foreign object—i.e. stent • Bladder • Stone nidus can form here secondary: • Dysfunctional bladder • Obstruction—i.e. BPH • Foreign object

  19. Symptoms—1 • Not all patients with stones have symptoms • Stones become symptomatic when: • Cause obstruction and irritation • Typical sites of obstruction: • Ureteral Pelvic Junction (UPJ) • Ureter crosses over Internal iliac vessels • UreteralVesical Junction (UVJ) • Associated with infection

  20. Symptoms—2 Classic symptoms: • ObstructionAcute, colicky pain • Can be severe • May have associated nausea and vomiting • Location of pain can suggest location of stone • Flank • Abdominal • Radiate to groin or testicle • Irritation urothelial lining Hematuria • Gross or microscopic • Irritation of bladder lining Lower urinary tract symptoms • Frequency • Urgency • Dysuria If associated with infectionFever

  21. Evaluation—1 • Laboratory tests: • CBC—elevated white blood cell count • BMP—elevated creatinine • UA—positive nitrites, leukocyte esterase • Order Urine culture • If febrile—Blood cultures • Imaging: • Non-contrasted CT • 1st line diagnostic test • Locate stone • Determine stone size • Identify signs of obstruction • hydronephrosis and hydroureter • KUB, Intravenous pyelogram (IVP), US

  22. Evaluation—2 • Success of spontaneous stone passage is correlated with: • Location of stone: • Distal > Proximal • Stone size: • 95% of stones < 5 mm will pass within 40 days 1Urology 10(6); 1977. Am J Roentgenol 178:101;2002. 2J Urol 162:688; 1999

  23. Evaluation—3 Which patients should undergo…. Trial of Passage (Surveillance) vs. Surgical Intervention • Indications for Hospital Admission: • Fever • Signs of infection • Elevated WBC • Solitary kidney • Intractable pain • Unable to tolerate fluid secondary to nausea/vomitting • Renal deterioration • Elevated creatinine attributed to obstruction

  24. Treatment—1 Trial of Passage (Surveillance) • Patient candidates: • Afebrile, pain controlled, no overt signs of infection or renal compromise • Medical management: • Oral hydration • Analegesics: tylenol, narcotics • Alpha blockers: Tamulosin (Flomax) • Relaxes ureteral smooth muscle • Increases stone passage rates up to ~ 44% • Decreases time to stone passage by ~2-4 days • Decreases pain associated with stone passage • Re-evaluate with imaging ~4-6 weeks • If stone remains….INTERVENTION becomes necessary

  25. Treatment—2 Patients with Active Infection • Initial treatment: • Antibiotics • Drainage of kidney • Ureteral stent • Percutaneousnephrostomy tube • Proceed with stone removal after infection has cleared Double J ureteral stents Nephrostomy tube

  26. Treatment—3 Treatment strategy based on…. Stone Size and Location • Options: • Kidney and ureteral stones: • Extracorporeal Shock Wave Lithotripsy (ESWL) • Percutaneousnephrolithotomy with lithotripsy (PCNL) • Ureteroscopy with lithotripsy/extraction • Open surgery (rare) • Bladder stones: • Cystolitholapaxy • Cystolithotomy (open surgery)

  27. Treatment—4 ESWL Most common 1st line treatment for renal calculi • Indications: • Non-obstructed renal or ureteral calculi < 1.5-2 cm • Contraindications: • Pregnancy • Coagulopathy • AAA (> 4cm) • Cystine, infectious stones (relative contraindication) • Advantages: • Non-invasive • Sedation only required • Outpatient intervention • Disadvantages: • Patients MUST pass stone fragments • Complications: • Steinstrasse 4-9%—may require 2nd intervention • Hematoma—renal/retroperitoneal

  28. Treatment—5 PCNL • Indications: • Renal pelvis calculi ~ > 2cm • Staghorn calculi • Proximal ureteral calculi ~ > 1cm • UPJ obstruction • Contraindications: • Coagulopathy • Advantages: • High stone free rate • Renal stones—95% • Ureteral stones—75% • Disadvantages: • Anesthesia • Overnight hospital stay • Ureteral stent and/or nephrostomy tube in perioperative period

  29. Treatment—6 Complications with PCNL • Bleeding • Risk of transfusion = 3% • Hemodynamically unstable • Return to the OR • Hemodynamically stable • Large diameter nephrostomy tube and clamp tube to tampanode bleeding • Nephrostomytampanode balloon catheter • Angiography and embolization • Pneumothorax/Hydrothorax • Percutaneous access: • Above 12th rib—10% risk of fluid in pleura • Above 11th rib—10% risk of pneumothorax/hydrothorax • Signs/symptoms: Pleuritic chest/flank pain, loss of breath sounds, respiratory distress/desaturation

  30. Treatment—6 Complications with PCNL • Bowel Injury • ~0.2% risk • Colonic injury more common • Left access • Morbidly obese • Intraoperative detection: contrast in colon with nephrostogram • Postoperative signs: Fecaluria, pneumaturia,peritoneal signs, fever, ileus, leukocystosis • Renal pelvis laceration/perforation • Can occur with dilation of percutaneous tract • Commonly detected intraoperatively • Postoperatively: common symptom—flank pain • Treatment: Placement of large bore nephrostomy tube until tract closes

  31. Treatment—7 Ureteroscopy (URS) • Indications: • Ureteral and lower pole renal stones • Morbid obesity • Bleeding diathesis • Ectopic or horseshoe kidney • Tools (aka toys): • Semi-rigid vs. flexible ureteroscope • Lithotripsy: laser, pneumatic, electrohydralic, ultrasonic • Extraction: stone grasper, basket • Advantages: • Outpatient procedure • High success rate of removal ~95% with Laser lithotripsy of ureteral stones • Disadvantages: • Anesthesia • Possible need for ureteral stent placement

  32. Treatment—8 Complications of URS • Ureteral false passage 0.4-0.9% • Entrance into ureteral orifice • Passing guidewire around impacted stone • Tx: Stent • Ureteral perforation 1-15% • More common with semi-rigid URS • Tx: Stent • Avulsion ~0.3% • Basketing large stone in proximal or mid-ureter • Complete avulsion requires operative repair • Ureteral Strictures 0-4% • Late complication • Increased risk with impacted stone, perforations Ureteral orifice Extravasation of contrast indicating perforation

  33. Follow Up Care—1 • Abbreviated Metabolic evaluation • First episode, solitary stone, uncomplicated course • UA, Ucx, stone analysis, BMP, Ca2+, Phosphorus, uric acid • Radiographic imaging • Extensive Metabolic evaluation • Recurrent episodes, medical conditions alter metabolism, non-calcium based stones • Same as abbreviated evaluation plus • 24 hr urine collection (~2x): urinary pH, volume, sodium, potassium, citrate, uric acid, magnesium, oxalate, chloride, protein, creatinine, cystine

  34. Follow Up Care—2 General Dietary Recommendations • Oral fluid intake • Keep urine volume 2-3L/day • Low sodium diet • Low animal protein diet • Low oxalate diet • Chocolate, tea, spinach, rhubarb, nuts, beets • Moderate calcium intake • 800-1000 mg/day Specific recommendations based on metabolic evaluation

  35. Clinical Scenario—1 64 yo female with no previous medical history presents to the ED with left lower quadrant abdominal pain and fever. On CT, she is found to have diverticulitis and incidentally a 5mm, nonobstructingrenal pelvic stone. How do you manage the stone? PCNL ESWL URS No immediate intervention necessary

  36. Clinical Scenario—2 32 yo male with no past medical history presents to clinic with left abdominal pain, hematuria, temperature of 38.5C, WBC 16. On CT he has a left 7mm mid-ureteral stone. What is the appropriate management? Immediate URS Trial of passage with flomax, narcotics Schedule outpatient ESWL Hospital admission, abx, stent

  37. Clinical Scenario—3 44 yo female POD #1 left PCNL with no nephrostomy tube develops worsening left flank pain, shortness of breath and shows a declining trend her oxygen saturations. What is the next step? Pain meds, nasal cannula, incentive spirometry Notify MD, likely needs CXR—pnuemothorax/hydrothorax Notify MD, likely needs CT scan—unidentified renal pelvic perforation Notify MD, likely needs nephrostomy tube—obstructing stone

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