Nephrolithiasis K17 .ppt...
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NEPHROLITHIASIS NEPHROLITHIASIS Surgical treatment andSurgical treatment and
metabolic evaluationmetabolic evaluationmetabolic evaluationmetabolic evaluation
Urology Division, Surgery DepartmentUrology Division, Surgery Department
Medical Faculty Medical Faculty
University of Sumatera Utara University of Sumatera Utara
PRESENTATIONPRESENTATION
�� Renal colicRenal colic
-- classically : flank pain, often acute inclassically : flank pain, often acute in
onset, radiating to the ipsilateral abdomenonset, radiating to the ipsilateral abdomen
-- distal ureteral stones distal ureteral stones �� ipsilateral groin,ipsilateral groin,-- distal ureteral stones distal ureteral stones �� ipsilateral groin,ipsilateral groin,
testicular (can mimic torsion ortesticular (can mimic torsion or
epididimytis), vulvar painepididimytis), vulvar pain
-- waxes & waneswaxes & wanes
-- frequently move about to find a more frequently move about to find a more
comfortable positioncomfortable position
RENAL COLIC
� Sudden onset, no relief with change of position
� Nause & vomiting
� Diagnosis studies :Diagnosis studies :
- urinalysis
- non-contrast CT scan
- plain radiograph
- white count and serum creatinin
- urine culture
- IVP
�� Nausea & vomitingNausea & vomiting
�� Irritative voiding symptomIrritative voiding symptom
�� Hematuria (gross or microscopic)Hematuria (gross or microscopic)�� Hematuria (gross or microscopic)Hematuria (gross or microscopic)
�� Urinary infectionUrinary infection
�� Fever, esp if infection presentFever, esp if infection present
�� Occasionally asymptomatic, with stones Occasionally asymptomatic, with stones
detected incidentallydetected incidentally
PAST MEDICAL HISTORYPAST MEDICAL HISTORY
�� ↓↓ fluid intakefluid intake
�� Urinary tract infectionUrinary tract infection
�� HighHigh--protein diet (associated with acidosis, protein diet (associated with acidosis, hypocitraturia, hypercalciuria, hypocitraturia, hypercalciuria, hypocitraturia, hypercalciuria, hypocitraturia, hypercalciuria, hyperuricosuria, hyperoxalouria)hyperuricosuria, hyperoxalouria)
�� IBD, small bowel resection, jejunoileal IBD, small bowel resection, jejunoileal bypass (hyperoxaluria & Ca oxalate stones)bypass (hyperoxaluria & Ca oxalate stones)
�� Primary hyperparathyroidism Primary hyperparathyroidism (hypercalciuria & Ca oxalate stone)(hypercalciuria & Ca oxalate stone)
�� Gout (uric acid stone)Gout (uric acid stone)
�� Total colectomy (uric acid stone)Total colectomy (uric acid stone)
�� RTA (Ca phosphate stones)RTA (Ca phosphate stones)
�� Medication :Medication :
-- steroids (hypercalciuria)steroids (hypercalciuria)
-- loop diuretics (hypercalciuria)loop diuretics (hypercalciuria)-- loop diuretics (hypercalciuria)loop diuretics (hypercalciuria)
-- colchicine (hyperuricosuria)colchicine (hyperuricosuria)
-- vitamin Dvitamin D
-- antacidsantacids
-- triamterenetriamterene
-- indinavirindinavir
�� Associated GU diseases:Associated GU diseases:
-- UPJ obstruction UPJ obstruction
-- bladder reconstructionbladder reconstruction
-- BPHBPH-- BPHBPH
-- medullary sponge kidney medullary sponge kidney
�� Family history of stonesFamily history of stones
�� Social history :Social history :
-- immobility and sedentary lifestyle immobility and sedentary lifestyle �� ↑↑ riskrisk
-- wine / beer wine / beer �� ↓↓ riskrisk
EVALUATION IN THE ACUTE SETTINGEVALUATION IN THE ACUTE SETTING
�� PHYSICAL EXAMPHYSICAL EXAM
-- evaluate for feverevaluate for fever
�� concomitant infection may beconcomitant infection may be�� concomitant infection may beconcomitant infection may be
associated with tachycardia and/or associated with tachycardia and/or
hypertensionhypertension
-- abdominal exam to evaluate for flankabdominal exam to evaluate for flank
tenderness/peritonitistenderness/peritonitis
URINALYSIS AND URINE CULTUREURINALYSIS AND URINE CULTURE
�� RBC usually present, WBC may be presentRBC usually present, WBC may be present
�� pH : pH : < 5.5 + radioluscent stone < 5.5 + radioluscent stone �� uric acid stoneuric acid stone
> 5.5 + metabolic acidosis, hypokalemia> 5.5 + metabolic acidosis, hypokalemia
& hyper chloremia & hyper chloremia �� RTARTA& hyper chloremia & hyper chloremia �� RTARTA
> 6.0 > 6.0 �� struvitstruvit
�� Crystals :Crystals :
-- Ca oxalate Ca oxalate �� dumbbell/hourglass/bipyramidaldumbbell/hourglass/bipyramidal
-- Ca phosphate Ca phosphate �� needleneedle--shaped/amorphousshaped/amorphous
-- uric acid uric acid �� amprphous/rosettesamprphous/rosettes
-- struvite struvite �� coffin lidcoffin lid
-- cystine cystine �� benzene ring/hexagonalbenzene ring/hexagonal
SERUM STUDIESSERUM STUDIES
�� Complete blood countComplete blood count
�� ElectrolytesElectrolytes
�� CalciumCalcium�� CalciumCalcium
�� PhosphatePhosphate
�� Uric acidUric acid
IMAGINGIMAGING
�� KUBKUB
-- 5 typical location of stone impaction :5 typical location of stone impaction :
calyxcalyxcalyxcalyx
ureteropelvic junction (UPJ)ureteropelvic junction (UPJ)
pelvic brim (iliacs)pelvic brim (iliacs)
posterior pelvis (broad ligament, females)posterior pelvis (broad ligament, females)
ureterovesical junction (UPJ)ureterovesical junction (UPJ)
�� Intravenous pyelogram (IVP)Intravenous pyelogram (IVP)
-- nowadays, rarely used in the acute settingnowadays, rarely used in the acute setting
�� UltrasoundUltrasound
-- pregnancy & pediatrics : avoids radiationpregnancy & pediatrics : avoids radiation
-- poor visualization of small renal & ureteralpoor visualization of small renal & ureteral
stonesstones
�� NonNon--contrast computed tomographycontrast computed tomography
-- 97% sensitive & 97% specific for stone97% sensitive & 97% specific for stone
-- 4 signs of obstruction :4 signs of obstruction :-- 4 signs of obstruction :4 signs of obstruction :
hydroureterhydroureter
perinephric strandingperinephric stranding
hydronephrosishydronephrosis
nephromegalynephromegaly
ACUTE MANAGEMENTACUTE MANAGEMENT
�� Pain control : Pain control : -- narcoticsnarcotics
-- NSAIDSNSAIDS
�� IV fluidsIV fluids
�� AB if urinary infection (+)AB if urinary infection (+)
Strain urineStrain urine�� Strain urineStrain urine
�� Recommended indication for admission :Recommended indication for admission :
-- uncontrolled painuncontrolled pain
-- unremitting nausea/vomiting with inability tounremitting nausea/vomiting with inability to
tolerate POtolerate PO
-- obstructed, infected renal unitobstructed, infected renal unit
-- obstructed, solitary renal unitobstructed, solitary renal unit
-- bilateral obstructionbilateral obstruction
-- anuriaanuria
�� Recommended indication for watchful waitingRecommended indication for watchful waiting
-- no evidence of infectionno evidence of infection
-- pain wellpain well--controlled with oral medicationcontrolled with oral medication
-- stone < 5 mmstone < 5 mm-- stone < 5 mmstone < 5 mm
-- no obstructionno obstruction
�� Spontaneous stone passage rates based on Spontaneous stone passage rates based on location :location :
-- proximal : 20%proximal : 20%
-- distal : 70%distal : 70%
�� Spontaneous passage rates within 1 year :Spontaneous passage rates within 1 year :
< 4 mm< 4 mm 90%90%
4 4 –– 6 mm6 mm 60%60%4 4 –– 6 mm6 mm 60%60%
> 6 mm> 6 mm 20%20%
Obstruksi ureter akut
prostaglandin
diuresis
Suspresi hormon anti diuretikVaso dilatasi ginjal
Peningkatan tekanan pelvis renalis
Nyeri meningkat
diuresis
Obstruksi ureter akut
Peningkatan tekanan pelvis renalis
Dilatasi pelvis renalis
Edema perirenal dan periureter
Kerusakan ginjal :terjadi oleh karena iskhemia ���� infark /
nekrosis pada duktus koligentes dan tubulus proksimalis
MEDICAL OPTIONS DURING MEDICAL OPTIONS DURING
EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT
�� Pain controlPain control
�� AB prophylaxisAB prophylaxis
�� Alpha blockersAlpha blockers�� Alpha blockersAlpha blockers
�� Ca channel blockersCa channel blockers
�� steroidssteroids
SURGERYSURGERY
�� ESWLESWL
-- imaging : fluoroscopyimaging : fluoroscopy
-- anesthesia : sedation or generalanesthesia : sedation or general
-- potential longpotential long--term renal effect :term renal effect :
renal injury/scar, hypertensionrenal injury/scar, hypertension
-- complications :complications :
hematoma (<1%) UTI/sepsishematoma (<1%) UTI/sepsis
obstruction injury to organobstruction injury to organ
-- contraindications :contraindications :
pregnancy calcified aneurysmpregnancy calcified aneurysm
morbid obesity bleeding diathesismorbid obesity bleeding diathesis
STONE FREE RATESSTONE FREE RATES
proximal distalproximal distal
ureter ureterureter ureter
<1.0 cm<1.0 cm
ESWLESWL 84%84% 85%85%ESWLESWL 84%84% 85%85%
UreteroscopyUreteroscopy 56%56% 89%89%
PCNLPCNL 76%76% --
≥1.0 cm≥1.0 cm
ESWLESWL 72%72% 74%74%
UreteroscopyUreteroscopy 44%44% 73%73%
PCNLPCNL 74%74% --
STONE FRAGMENTATION TECHNOLOGIESSTONE FRAGMENTATION TECHNOLOGIES
�� Electrohydraulic lithotripsyElectrohydraulic lithotripsy
�� Holmium : YAG laserHolmium : YAG laser
�� Ballistic lithotripsy (pneumatic)Ballistic lithotripsy (pneumatic)�� Ballistic lithotripsy (pneumatic)Ballistic lithotripsy (pneumatic)
�� Ultrasonic lithotripsyUltrasonic lithotripsy