URETERAL STONES Current Review of Diagnosis and Treatment

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URETERAL STONES: URETERAL STONES: A Brief Review of A Brief Review of Diagnosis Diagnosis and Treatment and Treatment

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URETERAL STONES Current Review of Diagnosis and Treatment

Transcript of URETERAL STONES Current Review of Diagnosis and Treatment

Page 1: URETERAL STONES Current Review of Diagnosis and Treatment

URETERAL STONES: URETERAL STONES: A Brief Review of Diagnosis A Brief Review of Diagnosis

and Treatmentand Treatment

Page 2: URETERAL STONES Current Review of Diagnosis and Treatment

EPIDEMIOLOGYEPIDEMIOLOGY

12% risk in lifetime 12% risk in lifetime

2-3% risk of renal colic2-3% risk of renal colic

Recurs within 2-3 yearsRecurs within 2-3 years

Occurs in men three times more than Occurs in men three times more than womanwoman

Peak incidence from 30 to 50Peak incidence from 30 to 50

Factors that may increase incidence: diet, Factors that may increase incidence: diet, lifestyle, social status, heredity, geography lifestyle, social status, heredity, geography

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TYPES OF STONESTYPES OF STONES

75% calcium oxalate or phosphate75% calcium oxalate or phosphate

15% phosphate-containing, most 15% phosphate-containing, most commonly struvite (magnesium commonly struvite (magnesium ammonium phosphate)ammonium phosphate)

5-10% uric acid5-10% uric acid

1% cystine1% cystine

Rarely, pure matrix and indinavir Rarely, pure matrix and indinavir depositiondeposition

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LOCATIONS OF STONESLOCATIONS OF STONES

Ureteropelvic junction (UPJ)Ureteropelvic junction (UPJ)

Pelvic brim (at the bifurcation of the iliac Pelvic brim (at the bifurcation of the iliac vessels where the ureter courses anterior vessels where the ureter courses anterior and medial to the vessels and is and medial to the vessels and is compressed)compressed)

Ureterovesical junction (UVJ)Ureterovesical junction (UVJ)

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URETERAL CALCULI

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L1/L2 JunctionL1/L2 Junction

Tips of transverse processesTips of transverse processes

Sacroiliac jointSacroiliac joint

Curves medially, Curves medially, Lateral to curve of sacrumLateral to curve of sacrum

Enters bladder near Enters bladder near sacro-coccygeal junction.sacro-coccygeal junction.Level with Ischial spinesLevel with Ischial spines

StoneStone

PhlebolithPhlebolith

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SIGNS AND SYMPTOMSSIGNS AND SYMPTOMS

Severe, intermittent unilateral flank that Severe, intermittent unilateral flank that radiates to the groin causing the patient to radiates to the groin causing the patient to writhe around at its height of intensitywrithe around at its height of intensity

Microscopic hematuriaMicroscopic hematuria

If febrile, then may be a complicated If febrile, then may be a complicated ureteral obstruction by either infection with ureteral obstruction by either infection with obstruction or acute pyelonephritisobstruction or acute pyelonephritis

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DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

Genitourinary causes: pyelonephritis, Genitourinary causes: pyelonephritis, torsion of a pelvic masstorsion of a pelvic mass

Gastrointestinal causes: appendicitis, Gastrointestinal causes: appendicitis, diverticulitis, cholecystitis, diverticulitis, cholecystitis, choledocholithiasis, pancreatitis, bowel choledocholithiasis, pancreatitis, bowel obstruction, Crohn’s disease, torsion of an obstruction, Crohn’s disease, torsion of an abdominal massabdominal mass

Vascular causes: aortic dissection, Vascular causes: aortic dissection, ruptured abdominal aortic aneurysmruptured abdominal aortic aneurysm

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PLAIN RADIOGRAPHYPLAIN RADIOGRAPHY

Relies solely on the identification of a Relies solely on the identification of a calcific density along the expected ureteral calcific density along the expected ureteral tracttract

Only 59% of ureteral calculi are visibleOnly 59% of ureteral calculi are visible

Cystine stones are mildly radiodenseCystine stones are mildly radiodense

Uric acid, pure matrix, and indinavir stones Uric acid, pure matrix, and indinavir stones are radiolucentare radiolucent

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ULTRASOUNDULTRASOUND

Not recommendedNot recommended

Detects indirect signs of obstruction: Detects indirect signs of obstruction: collecting system dilatation, a change in collecting system dilatation, a change in renal blood flow, a loss of a ureteric jetrenal blood flow, a loss of a ureteric jet

Rarely identifies urolithiasis except at the Rarely identifies urolithiasis except at the UPJ or UVJUPJ or UVJ

Difficulty in measuring the size of a stoneDifficulty in measuring the size of a stone

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INTRAVENOUS PYELOGRAM INTRAVENOUS PYELOGRAM (IVP)(IVP)

Advantages: availability, low cost, ability to Advantages: availability, low cost, ability to assess renal functionassess renal function

Disadvantages: requires intravenous Disadvantages: requires intravenous contrast, prolonged exam time, inability to contrast, prolonged exam time, inability to assess other causes of the clinical assess other causes of the clinical presentation, difficulty in distinguishing presentation, difficulty in distinguishing calcific densitiescalcific densities

Sensitivity 87% and specificity 94%Sensitivity 87% and specificity 94%

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IVP: Radiographic Findings of IVP: Radiographic Findings of Ureteral Stone ObstructionUreteral Stone Obstruction

Opacity along the urinary tractOpacity along the urinary tract

Dilatation of ureter down to obstructionDilatation of ureter down to obstruction

Dilatation of collecting systemDilatation of collecting system

Delay in contrast of nephrogramDelay in contrast of nephrogram

Delay in contrast of collecting systemDelay in contrast of collecting system

Delay in contrast excretionDelay in contrast excretion

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IVP: Radiographic Findings of IVP: Radiographic Findings of Ureteral Stone ObstructionUreteral Stone Obstruction

Figure1. a. An opacity is visible within the pelvis on the right side. b. The right ureter is full of contrast down to the site of obstruction.

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NONCONTRAST HELICAL CT NONCONTRAST HELICAL CT (NCCT)(NCCT)

Imaging modality of choiceImaging modality of choice

Advantages: speed, safety, ability to assess Advantages: speed, safety, ability to assess other causes of the clinical presentation, other causes of the clinical presentation, and in some places, equivalent cost to IVPand in some places, equivalent cost to IVP

Disadvantages: Inability to assess renal Disadvantages: Inability to assess renal function, difficulty in assessing patients that function, difficulty in assessing patients that have insufficient renal fat, difficulty in have insufficient renal fat, difficulty in distinguishing calcific densitiesdistinguishing calcific densities

Sensitivity 95% and specificity 95% Sensitivity 95% and specificity 95%

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NCCT: Direct Stone NCCT: Direct Stone VisualizationVisualization

Hallmark finding is a stone in the lumen of Hallmark finding is a stone in the lumen of the ureter on the side of renal colicthe ureter on the side of renal colic

Virtually all stones are seen on CT except Virtually all stones are seen on CT except pure matrix and indinivar stonespure matrix and indinivar stones

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NCCT: Secondary Signs of NCCT: Secondary Signs of Ureteral ObstructionUreteral Obstruction

Ureteral dilatationUreteral dilatation

Collecting system dilatationCollecting system dilatation

Perinephric strandingPerinephric stranding

Periureteric strandingPeriureteric stranding

NephromegalyNephromegaly

““Rim sign”Rim sign”

Absence of the white pyramidsAbsence of the white pyramids

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MAGNETIC RESONANCE MAGNETIC RESONANCE UROGRAPHY (MRU)UROGRAPHY (MRU)

Identifies stones and Identifies stones and some secondary some secondary signs of obstructionsigns of obstruction

Advantages: no Advantages: no radiation and contrastradiation and contrast

Disadvantages: Disadvantages: inability to image inability to image unobstructed urinary unobstructed urinary tract, expensive, slowtract, expensive, slow

Figure 7. MRU show obstruction of the right ureter.

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URETERAL CALCULIURETERAL CALCULI

TREATMENT CONSIDERATIONS

LocationLocation

SizeSize

ChronicityChronicity

EquipmentEquipment

ExpertiseExpertise

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URETERAL CALCULIURETERAL CALCULI

TREATMENT OPTIONSObservationObservation

Shock wave lithotripsyShock wave lithotripsy

UreteroscopyUreteroscopy

Blind basket extractionBlind basket extraction

Percutaneous approachPercutaneous approach

Open surgeryOpen surgery

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CONSERVATIVE CONSERVATIVE MANAGEMENTMANAGEMENT

Analgesics, hydration, and possibly Analgesics, hydration, and possibly antispasmodicsantispasmodics

Follow plain radiographs at 1-2 week Follow plain radiographs at 1-2 week intervalsintervals

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URETERAL CALCULI

SPONTANEOUS PASSAGE

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Of all stonesOf all stonesthat pass that pass spontaneouslspontaneously, 95% will y, 95% will pass within 6 pass within 6 weeksweeks

URETERAL CALCULISPONTANEOUS PASSAGE

Miller & Kane, 1999

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URETERAL CALCULIMEDICAL MANAGEMENT

Hollingsworth & Hollenbeck, 2006

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URETERAL CALCULIMEDICAL MANAGEMENT

Hollingsworth & Hollenbeck, 2006

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INTERVENTIONAL INTERVENTIONAL MANAGEMENT: Current MANAGEMENT: Current

TherapyTherapy

Extracorporeal shock wave lithotripsy (for Extracorporeal shock wave lithotripsy (for proximal ureteral stones and least invasive proximal ureteral stones and least invasive therapy)therapy)

Ureteroscopy (for mid and distal ureteral Ureteroscopy (for mid and distal ureteral stones)stones)

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URETERAL CALCULIURETERAL CALCULI

Stone-free is not everything !!Stone-free is not everything !!

PARAMETERS FOR COMPARISON

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URETERAL CALCULIURETERAL CALCULI

EffectivenessEffectiveness

MorbidityMorbidity

ConvalescenceConvalescence

CostCost

PARAMETERS FOR COMPARISON

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DISTAL URETERAL CALCULIDISTAL URETERAL CALCULI

URS is 10 - 18% more effective than SWL URS is 10 - 18% more effective than SWL (depending on type of SWL unit)(depending on type of SWL unit)

Morbidity / convalescence reduced with SWLMorbidity / convalescence reduced with SWL

Need for stents 40-60% less with SWLNeed for stents 40-60% less with SWL

Cost issues not addressed in monotherapy Cost issues not addressed in monotherapy studiesstudies

COMPARISON OFMONOTHERAPY STUDIES

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DISTAL URETERAL CALCULIDISTAL URETERAL CALCULI

SWLSWL URSURS

EffectivenessEffectiveness Slightly better Slightly better

MorbidityMorbidity LessLess

HospitalizationHospitalization LessLess

CostCost Slightly lessSlightly less

OVERVIEW OF HISTORICALCONTROL STUDIES

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DISTAL URETERAL CALCULIDISTAL URETERAL CALCULI

80 patients randomized to receive SWL or URS80 patients randomized to receive SWL or URS40 patients had stones > 5 mm40 patients had stones > 5 mm40 patients had stones < 5 mm40 patients had stones < 5 mm

SWL performed on Dornier MFL 5000SWL performed on Dornier MFL 5000

URS performed with 6.5F or 9.5F semi-rigid URS performed with 6.5F or 9.5F semi-rigid ureteroscopes (basket vs. pneumatic lithotripsy)ureteroscopes (basket vs. pneumatic lithotripsy)

PROSPECTIVE, RANDOMIZED TRIAL

Peschel & Bartsch, 1999

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DISTAL URETERAL CALCULIDISTAL URETERAL CALCULI

URSURS SWLSWLOR time (min)OR time (min) 19 19 6363Fluoro time (min)Fluoro time (min) 0.80.8 5.15.1Stone-free (days)Stone-free (days) 0.20.2 10.810.8Stent (days)Stent (days) 7.27.2 00Re-treatment rateRe-treatment rate 00 15%15%

PROSPECTIVE, RANDOMIZED TRIALSTONES < 5 MM

Peschel & Bartsch, 1999

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URETEROSCOPYURETEROSCOPY

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UreteroscopyUreteroscopy

Easier for lower Easier for lower stonesstonesExtraction of stone Extraction of stone fragmentsfragmentsFragmentationFragmentation– Laser Homium YgLaser Homium Yg– Mechanical EKLMechanical EKL– Explosive EHLExplosive EHL– UltrasoundUltrasound

RisksRisks

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URETERAL CALCULIFLEXIBLE URETEROSCOPY

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URETERAL STONE URETERAL STONE MANAGEMENTMANAGEMENT

URETEROSCOPYAdvantagesAdvantages

Highest success rateHighest success rateDefinitive Rx - No waiting for stone Definitive Rx - No waiting for stone passagepassage

DisadvantagesDisadvantagesMore invasive than SWLMore invasive than SWLHigher complication rateHigher complication rateRequires greater technical expertiseRequires greater technical expertise

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Rigid ureteroscope specifications Rigid ureteroscope specifications include the following:include the following:

Tip diameter - 4.5-9.5F (6.9F most Tip diameter - 4.5-9.5F (6.9F most common) common)

Optics - Fiberoptic bundles Optics - Fiberoptic bundles

Working channels - One, 2, or 3 (2 Working channels - One, 2, or 3 (2 channels preferred) channels preferred)

Accessory length - Average, 40 cmAccessory length - Average, 40 cm

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Flexible ureteroscope specifications Flexible ureteroscope specifications include the followinginclude the following

Tip diameter - 6.9-9.8F (7.5F most Tip diameter - 6.9-9.8F (7.5F most common) common)

Optics - Fiberoptic bundles Optics - Fiberoptic bundles

Working channel - Single, 3.6F Working channel - Single, 3.6F

Access - Guidewire (0.035 in nitinol or Access - Guidewire (0.035 in nitinol or 0.038 in stainless steel) 0.038 in stainless steel)

Accessory length - Average, 100 cmAccessory length - Average, 100 cm

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INTERVENTIONAL INTERVENTIONAL MANAGEMENT: More Invasive MANAGEMENT: More Invasive

TreatmentsTreatments

Intracorporeal shock wave lithotripsy Intracorporeal shock wave lithotripsy (through ureteroscope)(through ureteroscope)

Percutaneous nephrostomy (for stones >2 Percutaneous nephrostomy (for stones >2 cm and in proximal collecting system)cm and in proximal collecting system)

Laparoscopy (if complicated)Laparoscopy (if complicated)

Open surgery (rarely done)Open surgery (rarely done)

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Thank youThank you