Urolithiasis

- bladder calculi

- ureteral calculi

- renal stone ot staghorn stone

- low urine volume (goal 35 ml/kg/day)

- hypercalciuria

- hypocitraturia

- hypomagnesuria

- hyperoxalouria (enteric hyperoxalouria, short bowel syndrome)

- hyperuricouria

- low fluid intake

- fluids such as apple juice, grape fruit, sodas

- high NaCl intake

- high protein intake

- low calcium intake

- history of prior kidney stone

- Type 1 renal tubular necrosis

Types

- calcium

- non-calcium

Calcium

- calcium oxalate

- calcium phosphate

Non-calcium

- uric acid

- struvite stone

- cystine stone

- acute obstruction of ureter (severe colic pain)

- flank pain refered to genitalia or lower abdominal pain

- nausea, vomiting may mislead and look like GI problem

- microhematuria likely

- chronic stone disease tend to be associated with large or multiple stones

- can be little or no pain

- may have impaired renal function, anemia, weight loss, etc.

- concomitant infection more likely

- painful urination

- blood in urine

- cloudy or dark urine

- lower abdominal pain

- frequent urination

- difficulty controlling urine flow

- urinalysis

- film KUB

- USG

- cystolitholapaxy or breaking stones apart (cystoscopy)

*clearly view in stones ≤ 2.5 cm เพราะ > 2 cm อาจเกิด bladder injury ให้ open แทน

prevent supersaturation

- more water enough to make 2 L of urine per day

- low oxalate and moderate Ca intake and treatment of hypercalcuria

- replace solubilizers เช่น citrate

- manipulate pH (cystine and uric acid)

Ureteral calculi

- Proximal

- mid

- diatal

- blood in urine

- painful urination (colicky pain)

- urinary tract obstruction and inability to urination cause ARF (acute renal failure), septicemia

- urinalysis: microscopic hematuria, pus or crystals that are typical of calculus

- USG abdomen

- radiography

- obstruction

- hydronephrosis

- infection

- impaction

- ureteral stricture

Management

- active stone removal

- medical expulsive therapy (MET)

- endoscopic stone removal

* Dormia basket

* Ureteric meatotomy

- Ureteroscopic stone removal

* transurethrally across the bladder into the ureter

* Push bang

- Lithotripsy in situ

* Open surgery: ureterolithotomy

How to manage

- small ureteral stones with good chance of passage (< 7 mm)

* allow time to pass (2-4 wk)

* lower ureter-ureteroscopic stone removal

* mid-upper ureter ESWL (Extracorporeal Shock Wave Lithotripsy)

- large ureteral stones (> 7 mm)

* ESWL

* ureteroscopic stone fragmentation

* open surgery

Active stone removal

Indication: depend on size, shape and site of stone

- stones ≤ 4 mm (80% spontaneous stone passage)

- stones ≥ 7 mm (very low stone passage)

- ureteric stones (proximal 25%, Mid 45%, distal 70%)

- occupation

- family history

- diet

- hydration

- small bowel disease

- medical conditions causing hypercalcuria

- medical conditions causing aciduria

- sever flank pain

- abdominal pain

- N/V

- fatigue

- elevated temperature, BP, respirations

- steady pain

- pain on urination,

- pink, red or brown urine

- oliguria and anuria in obstruction

- hematuria

- renal colic

- hydronephosis

Types of renal calculi

Management

- ESWL

- Percutaneous nephrolithotomy (PCNL)

- Flexible ureteroscopy (RIRS-Retrograde intrarenal surgery )

- Open surgery

- pyelolithotomy

- extended pyelolithotomy

- nephrolithotomy

ESWL

complications

- ureteric colic

- infection after broken calculus

- renal haematoma

- severe haematuria

- steinstasse (stone street)

PCNL

definition?

- antegrade instrumentation of upper urinary tract via percutaeous puncture

indication?