11/16/2010. References. Epidemiology. Epidemiology

Transcription

1 References Urology Division, Surgery Department Medical Faculty, University of Sumatera Utara Epidemiology Prevalence of kidney stone 1 15 %, and in hot area such as the mountains, desert & tropical areas : = 2 to 3 : 1, peak age onset yrs The third most common affliction of the urinary tract, after UTI and pathologic conditions of the prostate Race : Whites > Asian > African Individual occupations eg. manager and professional risk of stone (unclear reason) Epidemiology 25% stone formers have a family history Risk of stone correlates with weight and body mass index Uric acid and Ca stones more frequent in, infectious stones more common in The most common kinds of stones are calcium oxalate, uric acid, struvite and cysteine 1

2 Etiology 1. Definitive causes : Metabolic Infection Anatomic Functional 2. Idiopathic Definitive causes Defects in purine metabolism (uric acid related disorders) Hyperoxaluric states - Primary hyperoxaluria - Enteric hyperoxaluria Hypercalcemic states - Primary hyperparathyroidism - Hyperthyroidism - Vitamin D abuse Hypercalcemic states (cont.) - Immobilization - Disseminated malignancies - Sarcoidosis - Renal tubular acidosis Chronic diarrheal states Cystinuria Urinary infection with urease producing microorganisms Anatomical and functional abnormalities Risk factors Genetics: Cystinuria : autosomal recessive RTA (renal tubular acidosis) type I Medullary sponge kidney Geography : temperature & humidity Diet : calcium / oxalate intake >> Profession : sedentary 2

3 Classification Non Calcium Stones Calcium Stones Defenition Infection stones: Magnesium ammonium phosphate Carbonate apatite Ammonium uratea Uric acid Ammonium uratea Sodium uratea Cystine Stone Composition and Relative Occurrence Stone Composition Occurrence (%) Calcium-Containing Stones Calcium oxalate 60 Hydroxyapatite 20 Brushite 2 Non Calcium-Containing Stones Uric acid 7 Struvite 7 Cystine 1 3 Triamterene <1 Silica <1 2,8-Dihyroxyadenine <1 Stone formation Stone formation Crystallization Nucleation Aggregation 3

4 Inhibitors and Promoters of Crystal Formation Inhibitors : Nephrocalcin Uropontin Tamm-Horsfall protein Citrate Magnesium Promoters : Calcium phospate Calcium oxalate Urinary tract stone Age Sex Profession Nutrition Climate Race Inheritance STONE Abnormal renal morphology Disturbed urin flow UTI Metabolic abnormal Genetic factors SUPER SATURATION Increase excretion of : 1. Stone forming constituents 2. Crystallization promoters Decrease : 1. Urinary volume 2. Excretion of crystallization inhibitors Pathogenesis CALCIUM STONES 1. Hipercalciuria 2. Hiperoksaluria 3. Hiperuricosuria 4. Hipositraturia 5. Hipomagnesuria URIC ACID STONES 5-10% of all stone 3 factors of uric acid stone formation : 1. Low ph, < 5,5 2. Low urine volume 3. Hyperuricosuria urinary uric acid less than 600 mg/day Secondary causes : gout (20%),obesity, myeloproliferative cancer and congenital disorder 4

5 STRUVITE STONES Infection stones comprise 5% to 15% of all stones Composed of Mg ammonium phosphate crystals or triple phosphate stone Staghorn calculi are typically struvite stone Caused by infection with urease-producing bacteria : - proteus is the most common - urease hydrolized urea to form ammonia alkalinizes the urine, ph and allows crystals to form CYSTINE STONES 1% of all stones Congenital disorders, autosomal recessive Caused by a defect in cystine reabsorption in the proximal tubule Cystine poorly soluble at normal ph (pka 8.3) Crystal form benzene ring on microscopy CALCIUM PHOSPHATE STONE Urine ph > 5.5 Hypocitraturia 70% of adults with type 1 RTA have stones 80% are women Associated with renal cyst Medications That directly Promote Stone Formation Indinavir Stones Triamterene Stones Guaifenesin and Ephedrine Silicate Stones 5

6 Anatomic Predisposition Ureteropelvic Junction Obstruction : 20 % cases Horseshoe Kidneys Caliceal Diverticula DIAGNOSIS History Physical examination Additional : Urine, microbiology Serum : kidney function, uric acid Plain x-ray / USG /IVP Recently : Computed tomography (CT), Magnetic resonance imaging (MRI), and endourology HISTORY Indications for a Metabolic Stone Evaluation The chief complaint is a constant reminder to the urologist as to why the patient initially sought care In obtaining the history of the present illness, the duration, severity, chronicity, periodicity, and degree of disability are important considerations Recurrent stone formers Strong family history of stones Intestinal disease (particularly chronic diarrhea) Pathologic skeletal fractures Osteoporosis History of urinary tract infection with calculi 6

7 Indications for a Metabolic Stone Evaluation Personal history of gout Infirm health (unable to tolerate repeated stone episodes) Solitary kidney Anatomic abnormalities Renal insufficiency Stones composed of cystine, uric acid, or struvite Basic Metabolic Evaluation HISTORY : Hyperparathyroidism or hypercalcaemia, Hyperuricemia, Renal tubular acidosis X-RAY STONE ANALYSIS : Ca, Uric Acid, Cystein, Carbonate etc. BLOOD : Serum Creatinin, Calcium, Uric Acid CLINICAL PRESENTATION Basic Metabolic Evaluation URINE : Urinary sediment/dipstick test for: - Red cells - White cells - Bacteriuria(nitrite) - Urine culture in case of a possible bacteriuria - ph PAIN Classically : flank pain, often acute in onset Located in the ipsilateral costoverteral angel Caused by distension of renal capsule May radiated to upper abdomen, umbilicus, testis or labium Pain by ureteral obstruction is typically colicky in nature and intensifies with ureteral peristalsis 7

8 PAIN Associated with gastrointestinal symptoms Ureteral pain is usually acute and secondary to obstruction Site of ureteral obstruction different referred pain - Right mid ureteral stone McBurney s point - Distal ureteral stones Ipsilateral groin, testicular (can mimic torsion or epididimytis), vulvar pain, supra pubic, urethra and tip of penis PAIN - waxes & wanes - frequently move about to find a more comfortable position Sudden onset, no relief with change of position CLINICAL PRESENTATION Nausea & vomiting Irritative voiding symptom Hematuria (gross or microscopic) Urinary infection Fever, esp if infection present Occasionally asymptomatic, with stones detected incidentally PHYSICAL EXAMINATION 1. Inspection : General overview of patient Local position?? Systemic component tachycardia, sweating and nausea 2. Palpation : Bimanual palpation of the kidney abdominal mass DRE : To exclude other patological conditions 8

9 URINALYSIS AND URINE CULTURE SERUM STUDIES RBC usually present, WBC may be present ph : < radioluscent stone uric acid stone > metabolic acidosis, hypokalemia & hyper chloremia RTA > 6.0 struvit Crystals : - Ca oxalate dumbbell/hourglass/bipyramidal - Ca phosphate needle-shaped/amorphous - uric acid amprphous/rosettes - struvite coffin lid - cystine benzene ring/hexagonal Complete blood count Electrolytes Calcium Phosphate Uric acid IMAGING KUB KUB - 5 typical location of stone impaction : calyx ureteropelvic junction (UPJ) pelvic brim (iliacs) posterior pelvis (broad ligament, females) ureterovesical junction (UPJ) 9

10 11/16/2010 Ultrasound Intravenous pyelogram (IVP) - nowadays, rarely used in the acute setting - pregnancy & pediatrics : avoids radiation - poor visualization of small renal & ureteral stones Imaging modalities Non-contrast computed tomography - 97% sensitive & 97% specific for stone - 4 signs of obstruction : hydroureter perinephric stranding hydronephrosis nephromegaly Preference number Examination LE 1. Non-contrast CT 1 2. Excretory urography (IVP) Standard Procedure 3.. KUB + USG 2a 10

11 ACUTE MANAGEMENT Pain control : - narcotics - NSAIDS IV fluids AB if urinary infection (+) Strain urine Recommended indication for admission : - uncontrolled pain - unremitting nausea/vomiting with inability to tolerate PO - obstructed, infected renal unit - obstructed, solitary renal unit - bilateral obstruction - anuria Pain relief for patients with acute stone colic Pharmacological agent 1. Diclofenac sodium 2. Indomethacin Ibuprofen 3. Hydromorphine hydrochloride (+ atropine) Methamizol Pentazocine Tramadol LE 1b 1b 4 Recommended indication for watchful waiting - no evidence of infection - pain well-controlled with oral medication - stone < 5 mm - no obstruction Spontaneous stone passage rates based on location : - proximal : 20% - distal : 70% Spontaneous passage rates within 1 year : < 4 mm 90% 4 6 mm 60% > 6 mm 20% 11

12 Obstruksi ureter akut Obstruksi ureter akut prostaglandin Peningkatan tekanan pelvis renalis Vaso dilatasi ginjal Suspresi hormon anti diuretik Dilatasi pelvis renalis diuresis Edema perirenal dan periureter Peningkatan tekanan pelvis renalis Nyeri meningkat Kerusakan ginjal : terjadi oleh karena iskhemia infark / nekrosis pada duktus koligentes dan tubulus proksimalis MEDICAL OPTIONS DURING EXPECTANT MANAGEMENT Pain control AB prophylaxis Alpha blockers Ca channel blockers steroids INDICATIONS FOR ACTIVE STONE REMOVAL The stone diameter is > 7 mm (because of a low rate of spontaneous passage) Pain relief cannot be achieved Stone obstruction associated with infection Pyonephrosis or urosepsis In single kidneys with obstruction Bilateral obstruction 12

13 SURGERY ESWL Ureteroscopy Percutaneous nephrolithotomy (PNL) Laparascopy Open surgery SURGERY ESWL - imaging : fluoroscopy - anesthesia : sedation or general - potential long-term renal effect : renal injury/scar, hypertension - complications : hematoma (<1%) obstruction - contraindications : pregnancy morbid obesity UTI/sepsis injury to organ calcified aneurysm bleeding diathesis ESWL : Extra Corporeal Shock Wave Lithotripsy STONE FREE RATES proximal ureter distal ureter <1.0 cm ESWL 84% 85% Ureteroscopy 56% 89% PCNL 76% cm ESWL 72% 74% Ureteroscopy 44% 73% PCNL 74% - 13

14 14