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Renal tract stones

Renal tract stones. Lachlan Brennan. Since the Stone Age. “I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work” Hippocrates 400BC. Pain. Agony. Misery. “Kidney stones”. Litho = stone

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Renal tract stones

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  1. Renal tract stones Lachlan Brennan

  2. Since the Stone Age “I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work” Hippocrates 400BC Pain Agony Misery

  3. “Kidney stones” • Litho = stone • Urolithiasis = stone in the urinary tract • Nephrolithiasis = stone in renal calyces/pelvis • Ureterolithiasis = stone in ureter • Cystolithiasis = stone in bladder • Calculi = stone

  4. Formation Solvent Solute Crystals Inhibitors Anatomical anchor: Renal calyces, PUJ, VUJ

  5. Chemical composition

  6. History Epidemiology • Lifetime prevalence 10-15% • Uncommon before age 20, peak 40s-60s, bimodal in women • Male > female 3 : 1 Sudden onset, unilateral flank pain • Radiation specific to site of stone – abdomen/back, groin/gonads, urethra • Haematuria, nausea & vomiting Risk factors

  7. Risk factors Personal history • Napoleon, Isaac Newton, Benjamin Franklin, Lyndon Johnson

  8. Examination Signs of renal colic • Unilateral flank tenderness (unreliable) • No peritonism Signs of complications • Fever, dehydration Differential diagnoses • Pyelonephritis, appendicitis, diverticulitis, salpingitis, ectopic pregnancy, AAA, testicular torsion, herpes zoster, biliary disease, renal cell carcinoma

  9. Investigation Pathology • In all – UEC, FBE, urine dipstick/MC&S, BhCG • In some – ionised calcium, uric acid, PTH, urinary products Imaging • Plain XR • CTKUB • Renal tract ultrasound • Intravenous pyelogram Opaque Lucent Cystine Struvite Calcium oxalate/phosphate Urate

  10. When to call Urology? Complicated vs. Uncomplicated • Large stone • Bilateral stones with obstruction • Evidence of shock or infection • Acute renal impairment • Anuria/oliguria • Solitary kidney, transplanted kidney • Pregnancy Does surgery need to be considered?

  11. Medical management Analgesia • NSAIDs (diclofenac, indomethacin) and opiates are roughly equivalent, can use both Anti-emesis Medical expulsive therapy • Tamsulosin (alpha-antagonist) Oral chemolysis Antibiotics for infection Prevention • Allopurinol for urate stones, dietary restriction of calcium/oxalate

  12. Wait and watch Spontaneous expulsion • Serial imaging, urine straining • Symptom management • Monitor for complications

  13. Surgical management Non-invasive approach • External shock wave lithotripsy Incisional approach • Percutaneous lithotomy • Open/laparoscopic surgery Endoscopic approach • Ureteroscopy and basket Ureteric stent placement

  14. Review • Common ED presentation • Clues on history and examination • Confirmation with investigation • Complicated vs. Uncomplicated • Call Urology • Consider medical as well as surgical Mx

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