Renal stones Dr Bandar Al Hubaishy Urology Department

Renal stones Dr. Bandar Al Hubaishy Urology Department KAUH

Clinical picture Renal stones: Small stones: n Pain Infection Hematouria

n Large renal stones: They are asymptomatic e. g. staghorn stones Which are associated by UTI

Ureteric stones: Renal colic: it is a severe colicky pain in the flank that can radiate to the groin and scrotum in male n Nausea and vomiting Hematouria Irritative symptoms as the stones in the distal part of the ureter

Physical examination n Costovertebral angel tenderness n No peritoneal signs

Work up Laboratory

n Urine analysis for evidence of hematouria and infection n CBC for evidence of systemic infection

n n n Serum electrolytes Serum calcium PTH Phosphate Uric acid

Metabolic screen n 24 hours urinary collection offor levels of p. H, calcium, oxalate, uric acid, sodium, phosphorus, citrate, magnesium, creatinine, and total volume

The goal of metabolic screen n To prevent future stone formation due to metabolic abrnomalities

Indications for metabolic screen n n n n Residual calculi after surgical treatment Initial presentation with multiple calculi Initial presentation before age 30 years Renal failure Solitary kidney (including renal transplant) Family history of calculi More than one stone in the past year Bilateral calculi

Imaging studies

KUB Renal ultrasound Spiral C. T abdomen without contrast IVP

KUB To detect radiopaque stones To follow up the radiopaque stone

Ultrasound For radiolucent stones and for pregnant stones To assess the presence of hydronephrosis It can not assess the presence of ureteric stones

IVP n It assess both function and anatomy of the renal system n Delayed nephrogram is the only hallmark for urinary tract obstruction

n Contraindications of IVP: Pregnancy Pediatric Allergy Mettformin Renal impairment

It is no longer used as the standard for the initial evaluation of a patient with a kidney stone : n n n Up to 6 hours may be required to complete the study in the presence of severe obstruction. For optimal results, IVU requires a bowel preparation. It involves intravenous injection of potentially allergic and mildly nephrotoxic contrast material

Spiral C. T abdomin and Pelvis without contrast n n n It is the best initial radiographic examination for acute renal colic. Advantages of a CT scanning include the following: It can reveal other pathology (eg, abdominal aneurysms, appendicitis, cholecystis). It can be performed quickly. It avoids the use of intravenous contrast materials.

n n n Disadvantages of CT scanning include the following: It cannot be used to assess individual renal function. It can fail to reveal some unusual radiolucent stones, such as those caused by indinavir, which are invisible on the CT scan. Because of this possibility, IVUs with contrast should be used for patients taking indinavir. It is relatively expensive.

n n n It exposes the patient to a relatively high radiation dose. Precise identification of small distal stones is occasionally difficult. It is not suitable for tracking the progress of the stone over time, supporting the recommendation for KUB radiography along with the CT scan.

MANAGEMENT

n It depends on the site , size and the general condition of the patient n The management involve medical and surgical management

Renal Stones n Small renal stones less than 0. 6 mm: Hydration Ebimag Follow up in the clinic with KUB every 2 weeks

n Renal stones size 0. 7 mm-2 cm: ESWL Hydration Analgesic KUB follow up in the clinic

n Renal stones bigger than 2 cm Percutaneous nephrostolithotomy (PCNL)

Ureteric Stones Non obstructing stone: n n n Hydration Ebimag Analgesic

n n Obstructing ureteric stone If the patient is stable, ureteroscopy and lithotripsy If the patient is not stable, do double j stent insertion or nephrostomy tube to decompress the obstruction