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RENAL STONE DISEASE

RENAL STONE DISEASE. ANALYSIS OF STONES. ______________________________ Oxalate 504 (56.1%) Triple phosphate 237 (26.4%) Phosphate 119 (13.4%) Uric acid 38 (4.2%) ______________________________

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RENAL STONE DISEASE

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  1. RENAL STONE DISEASE

  2. ANALYSIS OF STONES ______________________________ Oxalate 504 (56.1%) Triple phosphate 237 (26.4%) Phosphate 119 (13.4%) Uric acid 38 (4.2%) ______________________________ Total 898 (100%)

  3. AGE DISTRIBUTION OF OXALATE STONES

  4. FORMATION OF STONES Urine pH/infection Renal damage Calcium/oxalate Tissue debris Anatomical stasis Fixed particles inhibitors Aggregation Stone formation

  5. FORMATION OF STONES 1. Calcium - a) hypercalcaemia b) hyperparathyroidism c) hypercalciuria 2. Oxalate - G1, hyperoxalaturia 3. Cystine 4. Uric Acid 5. Infection - Urea-splitting organisms 6. Congenital / metabolic defects: - medullary spone kidney - renal tubular acidosis

  6. CLINICAL PRESENTATION 1. Flank/loin pain, colicky + radiation - haematuria - nausea and vomiting - chills/fever/frequency, if infected 2. Loin tenderness 3. Bilateral stones : renal failure

  7. INVESTIGATIONS 1. IVU and DTPA • Serum creatinine calcium • Urine pH 4. 24-hour urine 5. Urine cultures 6. Stone analysis

  8. METABOLIC ABNORMALITIES(N = 392) Hypercalciuria 28% Hyperoxaluria 16% Hyperuricosuria 14% Cystinuria 0.5% Hyperparathyroidism 1% Primary oxalosis 0.25% Renal tubular acidosis 0.25%

  9. INDICATIONS FOR TREATMENT Presence of symptoms and / or obstructive uropathy in a functioning kidney

  10. Treatment of Renal Stones Four Options 1) conservative 2) non-invasive: ESWL 3) minimal invasive : PCNL, URS 4) open surgery New technology :  morbidity,  hospital stay,  invasiveness

  11. Electromagnetic Shockwave

  12. MANAGEMENT OF RENAL CALCULI by ESWL < 2cm in diameter and/or surface area < 500 mm2 Treatment : ESWL monotherapy > 2cm in diameter and/or surface area > 500 mm2 Treatment : PCNL +/- ESWL Combination therapy

  13. MANAGEMENT OF RENAL CALCULI by ESWL > 2cm in diameter and/or surface area > 500 mm J Stents + ESWL with repeated treatments required

  14. ESWL for Staghorn Stones PCNL + ESWL as main option ESWL monotherapy is discouraged Open surgery has a place for large complete staghorn calculi

  15. Contra-indications to the Use of ESWL Absolute contra-indications • Pregnancy • Untreated urinary tract infection • Distal obstruction to the stone that cannot be bypassed by a stent • Untreated bleeding diatheses • Non-functioning kidney

  16. PCNL

  17. Percutaneous Nephroscope and Lithoclast

  18. PCNL

  19. Results of Percutaneous Nephrolithotripsy PCNL Indications : High stone burden or failed ESWL Success : Stones free 82% Insignificant fragments 15% Failure : Stones > 4cm in diameter 3%

  20. Traumatic AV Fistula after PCNL

  21. MANAGEMENT OF URETERIC STONES -Stones < 0.5 cm in diameter doesn’t pass spontaneously 4 to 6 weeks and /or causing symptoms : ESWL monotherapy -Stones > 0.5 cm in diameter & < 1 cm in diameter : ESWL monotherapy

  22. MANAGEMENT OF URETERIC STONES Stones > 1 cm in diameter : trial of ESWL monotherapy Patient counselled: 1. Repeat session may be necessary 2. URS/PCNL/ureterolithotomy

  23. RESULTS OF URETROSCOPIC LITHOTRIPSY (URS) Achieved stone free status = 85% to 90% Failures: 1. Access problems 2. Stone migration Flexible URS for upper third ureteric calculi especially in the male

  24. Ureteric stone suitable for ESWL

  25. URS with Guide wire

  26. Laser Lithotripsy

  27. OPEN STONE SURGERY 2% incidence of all stone treatments Indications: 1.Complex stone burden 38% 2. Non-functioning kidneys 20% 3. Failure of MIS 16% 4. Others 26%

  28. Recurrent Rate 75% - 10 Years 100% - 20 Years(Williams 1963)

  29. PREVENTION OF STONES 1. Treatment of causes 2. Dietary manipulations 3. Medications - indication duration

  30. DIETARY ADVICE 1. Hydration 2. Avoid oxalate-rich food 3. Avoid calcium-rich food ? 4. Avoid refined carbohydrates 5. Increase crude fibres

  31. MEDICATIONS 1. Thiazides 2. Allopurinol 3. Antibiotics 4. Sodium bicarbonate 5. Potassium citrate 6. Magnesium salts 7. Pyridoxine

  32. Cystine Stone • 1% of stone population • Autosomal recessive • Round stones in calyces • Large staghorn stones • Hexagonal crystals

  33. Medical Treatment - Cystine • Volume at 2.5 l/day • Increase pH to > 7.0 • Decrease dietary protein • D-penicillamine, thiola • Side-effects : marrow / nephrotic

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