Ureteric Stones
Transcript of Ureteric Stones
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URETERAL STONES:
A Brief Review of Diagnosis
and Treatment
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EPIDEMIOLOGY
12% risk in lifetime
2-3% risk of renal colic
Recurs within 2-3 yearsOccurs in men three times more than
woman
Peak incidence from 30 to 50Factors that may increase incidence: diet,
lifestyle, social status, heredity, geography
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TYPES OF STONES
75% calcium oxalate or phosphate
15% phosphate-containing, most
commonly struvite (magnesium
ammonium phosphate)
5-10% uric acid
1% cystineRarely, pure matrix and indinavir
deposition
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LOCATIONS OF STONES
Ureteropelvic junction (UPJ)
Pelvic brim (at the bifurcation of the iliac
vessels where the ureter courses anterior
and medial to the vessels and is
compressed)
Ureterovesical junction (UVJ)
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URETERAL CALCULI
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L1/L2 Junction
Tips of transverse processes
Sacroiliac joint
Curves medially,
Lateral to curve of sacrum
Enters bladder near
sacro-coccygeal junction.
Level with Ischial spines
Stone
Phlebolith
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SIGNS AND SYMPTOMS
Severe, intermittent unilateral flank that
radiates to the groin causing the patient to
writhe around at its height of intensity
Microscopic hematuria
If febrile, then may be a complicated
ureteral obstruction by either infection with
obstruction or acute pyelonephritis
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DIFFERENTIAL DIAGNOSIS
Genitourinary causes: pyelonephritis,
torsion of a pelvic mass
Gastrointestinal causes: appendicitis,
diverticulitis, cholecystitis,
choledocholithiasis, pancreatitis, bowel
obstruction, Crohns disease, torsion of an
abdominal mass
Vascular causes: aortic dissection,
ruptured abdominal aortic aneurysm
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PLAIN RADIOGRAPHY
Relies solely on the identification of a
calcific density along the expected ureteral
tract
Only 59% of ureteral calculi are visible
Cystine stones are mildly radiodense
Uric acid, pure matrix, and indinavir stonesare radiolucent
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ULTRASOUND
Not recommended
Detects indirect signs of obstruction:
collecting system dilatation, a change in
renal blood flow, a loss of a ureteric jet
Rarely identifies urolithiasis except at the
UPJ or UVJ
Difficulty in measuring the size of a stone
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INTRAVENOUS PYELOGRAM
(IVP)Advantages: availability, low cost, ability to
assess renal function
Disadvantages: requires intravenous
contrast, prolonged exam time, inability to
assess other causes of the clinical
presentation, difficulty in distinguishing
calcific densities
Sensitivity 87% and specificity 94%
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IVP: Radiographic Findings of
Ureteral Stone ObstructionOpacity along the urinary tract
Dilatation of ureter down to obstruction
Dilatation of collecting systemDelay in contrast of nephrogram
Delay in contrast of collecting system
Delay in contrast excretion
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IVP: Radiographic Findings of
Ureteral 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
(NCCT)
Imaging modality of choice
Advantages: speed, safety, ability to
assess other causes of the clinicalpresentation, and in some places,
equivalent cost to IVP
Disadvantages: Inability to assess renal
function, difficulty in assessing patients
that have insufficient renal fat, difficulty
in distinguishing calcific densities
Sensitivit 95% and s ecificit 95%
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NCCT: Direct Stone
VisualizationHallmark finding is a stone in the lumen of
the ureter on the side of renal colic
Virtually all stones are seen on CT except
pure matrix and indinivar stones
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NCCT: Secondary Signs of
Ureteral ObstructionUreteral dilatation
Collecting system dilatation
Perinephric strandingPeriureteric stranding
Nephromegaly
Rim signAbsence of the white pyramids
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MAGNETIC RESONANCE
UROGRAPHY (MRU)Identifies stones and
some secondary
signs of obstruction
Advantages: noradiation and contrast
Disadvantages:
inability to image
unobstructed urinary
tract, expensive, slowFigure 7. MRU show obstruction of the right ureter.
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URETERAL CALCULI
TREATMENT CONSIDERATIONS
LocationSize
Chronicity
Equipment
Expertise
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URETERAL CALCULI
TREATMENT OPTIONSObservation
Shock wave lithotripsyUreteroscopy
Blind basket extraction
Percutaneous approachOpen surgery
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CONSERVATIVE
MANAGEMENTAnalgesics, hydration, and possibly
antispasmodics
Follow plain radiographs at 1-2 week
intervals
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URETERAL CALCULI
SPONTANEOUS PASSAGE
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Of all stones
that passspontaneously, 95% willpass within 6weeks
Average Days to Stone Passage
05
10
1520
25
2 mm 3 mm 4 - 6mm
Stone Size
Days
Avg Days
URETERAL CALCULISPONTANEOUS PASSAGE
Miller & Kane, 1999
URETERAL CALCULI
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URETERAL CALCULIMEDICAL MANAGEMENT
Hollingsworth & Hollenbeck, 2006
URETERAL CALCULI
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URETERAL CALCULIMEDICAL MANAGEMENT
Hollingsworth & Hollenbeck, 2006
INTERVENTIONAL
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INTERVENTIONAL
MANAGEMENT: Current
Therapy
Extracorporeal shock wave lithotripsy (for
proximal ureteral stones and least invasivetherapy)
Ureteroscopy (for mid and distal ureteral
stones)
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URETERAL CALCULI
Stone-free is not everything !!
PARAMETERS FOR COMPARISON
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URETERAL CALCULI
Effectiveness
Morbidity
Convalescence
Cost
PARAMETERS FOR COMPARISON
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DISTAL URETERAL CALCULI
URS is 10 - 18% more effective than SWL(depending on type of SWL unit)
Morbidity / convalescence reduced with SWL
Need for stents 40-60% less with SWL
Cost issues not addressed in monotherapystudies
COMPARISON OF
MONOTHERAPY STUDIES
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DISTAL URETERAL CALCULI
SWL URS
Effectiveness Slightly better
Morbidity LessHospitalization Less
Cost Slightly less
OVERVIEW OF HISTORICALCONTROL STUDIES
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DISTAL URETERAL CALCULI
80 patients randomized to receive SWL or URS 40 patients had stones > 5 mm
40 patients had stones < 5 mm
SWL performed on Dornier MFL 5000URS performed with 6.5F or 9.5F semi-rigidureteroscopes (basket vs. pneumatic lithotripsy)
PROSPECTIVE, RANDOMIZED TRIAL
Peschel & Bartsch, 1999
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DISTAL URETERAL CALCULI
URS SWLOR time (min) 19 63
Fluoro time (min) 0.8 5.1
Stone-free (days) 0.2 10.8Stent (days) 7.2 0
Re-treatment rate 0 15%
PROSPECTIVE, RANDOMIZED TRIALSTONES < 5 MM
Peschel & Bartsch, 1999
**
***
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URETEROSCOPY
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Ureteroscopy
Easier for lowerstones
Extraction of stonefragments
Fragmentation Laser Homium Yg
Mechanical EKL
Explosive EHL Ultrasound
Risks
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URETERAL CALCULIFLEXIBLE URETEROSCOPY
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URETERAL STONEMANAGEMENT
URETEROSCOPY
Advantages
Highest success rateDefinitive Rx - No waiting for stonepassage
DisadvantagesMore invasive than SWLHigher complication rateRequires greater technical expertise
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Rigid ureteroscope specifications
include the following:
Tip diameter - 4.5-9.5F (6.9F most
common)
Optics - Fiberoptic bundles
Working channels - One, 2, or 3 (2
channels preferred)
Accessory length - Average, 40 cm
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Flexible ureteroscope
specifications include the following
Tip diameter - 6.9-9.8F (7.5F most
common)
Optics - Fiberoptic bundlesWorking channel - Single, 3.6F
Access - Guidewire (0.035 in nitinol or
0.038 in stainless steel)Accessory length - Average, 100 cm
INTERVENTIONAL
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INTERVENTIONAL
MANAGEMENT: More Invasive
TreatmentsIntracorporeal shock wave lithotripsy
(through ureteroscope)Percutaneous nephrostomy (for stones >2
cm and in proximal collecting system)
Laparoscopy (if complicated)Open surgery (rarely done)
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Thank you