Management of Urolithiasis : Stone Formation in the Urinary System

Physical Evaluation
Costovertebral angle or lower abdominal tenderness.
Complete blood count
Renal functions.

Indications for Urgent Intervention
Presence of infection with urinary tract obstruction.
B/L obstructing stones
Solitary kidney

Unenhanced helical CT scan is the investigation of choice.
IVU was the gold standard but now has been replaced by CT.
Plain abdominal radiograph can determine weather a stone is radio-opaque and can be used to monitor disease activity.
Ultrasound is usually not recommended because of low sensitivity but is often used in pregnant patients.

Principal guiding treatment are to maximize stone clearance and minimize patient morbidity.
Open surgery has been supplanted by less invasive methods.
Shock wave lithotripsy is the commonest treatment for renal stones (stone burden of <2cm aggregate diameter).
Ureteroscopy is indicated when SWL fails, when  complex or lower pole renal calculi are present, or in pregnancy, morbid obesity or coagulopathy.
For complex renal calculi ( stone burden of >2cm, stag horn calculi, abnormal anatomy) resistant to fragmentation percutaneous nephrolithotomy is the treatment of choice.
Proximal ureteral calculi best treated by SWL
Distal ureteral calculi often require Ureteroscopy.
Most ureteral calculi <5mm in diameter will pass spontaneously within 4 weeks of symptom onset.
The use of drugs to help spontaneous passage of stones is a new approach.
Drugs including calcium channel blockers, steroids and alpha-adrenergic blockers have been recently investigated.

Sunday, September 14, 2014