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