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Management Of Ureteric Stones by alphauro

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Management Of Ureteric Stones

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									Management Of Ureteric Stones: An update
BY
Ahmed A. Shokeir, MD, PhD, FEBU Professor of Urology From Urology & Nephrology Center, Mansoura - Egypt
Shokeir A.A.

Management Of Ureteric Stones: An update
Update of diagnosis Update of treatment

Special situations
 Children  Pregnancy
Shokeir A.A.

Management Of Ureteric Stones: An update Update of Diagnosis

Shokeir A.A.

Diagnosis Of Ureteric Stones
Traditional Methods: History and clinical examination KUB Gray-scale US IVP Recent Methods (revolution) Doppler US (RI, ureteric jets) Noncontrast CT Others less common method: MRI Renogram
Shokeir A.A.

Clinical Diagnosis of Ureteric Stones Renal Colic
History Colicky pain from the loin to the groin Haematuria Gastro-intestinal symptoms Site of referral:
Upper ureter Mid ureter Lower ureter
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Accuracy of Clinical Diagnosis
Haddad et al (Radiology, 1992) Riyadh Armed Forces Hospital Sensitivity: Specificity: Overall accuracy:
Shokeir A.A.

73% 46% 70%

Diagnosis of Ureteric Stones Clinical Scoring System Eskelinen et al, (Euro Urol. 1998)
The most significant predictors of acute renal colic are:
1. Acute abdominal pain with short

duration ( 12 h)
2. loin or renal tenderness 3. Haematuria (RBC > 10 /HPF)
Shokeir A.A.

Diagnosis of Ureteric Stones KUB Of limited value (sensitivity 45- 59%).

Limitations:
Superimposed bowel and bone

Non- opaque calculi
Vascular calcifications (phleboli)

Not sufficient alone to diagnose stone disease.
Shokeir A.A.

Diagnosis of Ureteric Stones Ultrsonography (US)
Advantages:
Non- invasive Quick Portable Repeatable Relatively inexpensive No ionizig radiation No contrast material Attractive in pregnancy Attractive in renal impairment
Shokeir A.A.

Diagnosis of Ureteric Stones US Conventional (gray scale US):
Direct role: visualization of stones Indirect role: pyelocaliectasis

Doppler US:
Resistive index Ureteric jets
Shokeir A.A.

Diagnosis of Ureteric Stones Gray- Scale US
Direct Role : (Visualization)
Pelvis &calyx

PUJ

Difficult

TRUS &TVUS Shokeir A.A.

Diagnosis of Ureteric Stones Gray- Scale US Indirect Role: (Pyelocaliectasis)
False negative: 20- 30 %
False positive:
Pyelonephritis.
VUR

Residual dilatation.
Overdistention of the bladder.
Shokeir A.A.

Diagnosis Of Ureteric Stones Doppler US RI
Definition:
(Peak sys. Velocity – Peak diast. Velocity) / Peak syst. velocity

Relation to obstruction:

 RI

Values diagnostic of obstruction:
Chronic: RI  0.70 Acute:
Shokeir A.A.

 RI 0.04

DUS in Renal Colic Role of RI
British journal of urology (1997). 80.195-200
Review Resistive index in obstructive uropathy A.A SHOKEIR, A. P. PROVOOST† and R. I. M. NIJMAN
__________________________________________________________________________________________________

BJU International (1999).84.249-251.

Resistive index in renal colic: the effect of nonsteroidal antiinflammatory drugs
A.A SHOKEIR M . ABDULMAABOOD. Y. FARAGE and H. MUTABAGANI
____________________________________________________________________

BJU International (1999).83. 378- 382

Resistive index in renal colic:a prospective study
A.A SHOKEIR and M . ABDULMAABOOD Shokeir A.A.

Diagnosis Of Ureteric Stones RI In Pregnant Women Shokeir et al, Urology, 2000  RI is a sensitive and specific test that can replace IVP in the diagnosis of acute unilateral ureteric obstruction in pregnant women
Shokeir A.A.

DUS in Renal Colic: Role of RI

Shokeir A.A.

Diagnosis Of Ureteric Stones
Doppler US

Ureteric Jets Patent ureter: normal jet
Complete obstruction: no jet Partial obstruction: low level jet that is asymmetric to the other ureter
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DUS In Renal Colic: Ureteric jets

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Diagnosis Of Ureteric Stones Doppler US Ureteric Jets
Disadvantages:
No objective parameters for measurement. Time consuming.

Current Indications:
Pregnancy
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Diagnosis Of Ureteric Stones Role of Noncontrast CT (NCCT)
Smith et al “Radiology 1995”
Sensitivity: 98%
Specificity: 100%

Shokeir A.A.

Diagnosis Of Ureteric Stones NCCT
Advantages
No contrast Visualize small radiolucent stones that may not be seen in IVP Very fast (5 min) Can identify other urinary and non urinary abnormalities to direct further imaging and management
Shokeir A.A.

Diagnosis Of Ureteric Stones NCCT
Interpretation
Regardless of composition, all stones are visible on NCCT Secondary NCCT signs of ureteric obstruction are:
 Ureteric and renal dilatation  Stranding of the perinephric fat  Perinepheric collection

 Soft tissue ring sign  Pale-kidney sign
Shokeir A.A.

NCCT

Shokeir A.A.

NCCT

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NCCT

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Diagnosis Of Ureteric Stones NCCT
Potential Pitfalls
Pelvic phleboli: can mimic ureteric stones. Gonadal vein: can be confused with a dilated ureter.
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NCCT

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Diagnosis Of Ureteric Stones NCCT
Disadvantages
No evaluation of renal function. No evaluation of urothelium. Expensive. High radiation limiting its use in pregnancy. Not universaly available.
Shokeir A.A.

Diagnosis Of Ureteric Stones NCCT VS RI
Shokeir et al, J Urol, 2001
Patients and Methods
109 patients with acute flank pain Subjected to:
 NCCT  DUS:  IVP:

 RI  0.04 gold standard

Shokeir A.A.

Diagnosis Of Ureteric Stones NCCT CT VS RI
Shokeir et al, J Urol, 2001 Results NCCT  RI Sensitivity: 98% 92% Specificity: Overall accuracy: 100% 99% 100% 96%

Shokeir A.A.

Diagnosis Of Ureteric Stones Noncontrast CT VS RI
Shokeir et al, J Urol, 2001

Conclusion
Both NCCT and  RI are sensitive and specific in the diagnosis of acute ureteric obstruction.They can replace IVP particularly in situations where IVP is undesirable.
Shokeir A.A.

Diagnosis Of Ureteric Stones
Role of IVP
Previous gold standard Current indications:
IVP is no longer the primary investigation in patients with suspected renal colic, however, it is still indispensable if endoscopic or open intervention is decided.
Shokeir A.A.

Other Methods of Diagnosis of RenalColic
MRI
Provides anatomical and functional information (alternative to IVP). No ionizing radiation (pregnancy , adolesence, children). No nephrotoxic contrast. Promising results. Studies are few. Limitations :
 

Shokeir A.A.

Expensive. Not universally available.

IVP

MRI

Shokeir A.A.

Other Methods of Diagnosis of Renal Colic
Renogram
Provides anatomical, functional urodynamic data of each kidney It has not gained much popularity Limitations: and

Expensive Using radioisotopes and ionizing radiation The results depend upon differential variables
Shokeir A.A.

Flank pain Clinical evaluation Suggestive of stone disease Nonsuggestive of stone disease

KUB , US & DUS
Stone present Stone absent Stone present NCCT Stone absent

Plan treatment Shokeir A.A.

Further work-up assuming stone disease is absent

Management Of Ureteric Stones: An update

Update of Treatment

Shokeir A.A.

Factors Affecting Treatment of Ureteric Stones
Stone Urinary tract

Patient
Hospital Doctor
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Ureteric Divisions
Upper Middle Lower
Proximal

Distal

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Methods Of Treatment
Conservative ESWL Ureteroscopy PCNL Laparoscopy Open surgery
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Conservative Management
Chance Of Spontaneous Passage
< 5mm 5-10 mm

Proximal
Distal
Shokeir A.A.

29-98%
71-98%

10-53%
25-53%

Conservative Management Prediction Of Spontaneous Passage
More likely
Small Distal Right side

Less likely
Big Proximal Left side

Shokeir A.A.

Conservative Management Average Time To Spontaneous Passage
mm
≤2

days
8

≤3
4-6

12
22

> 2 months → No spontaneous passage
Shokeir A.A.

Conservative Management Renal Function
General trend
Short-lived, partial obst. → no long-term irreversible damage.

Holm-Nielsen et al 1981
Obst. > 4 week → irreversible damage in 1/3 patients

Irving et al 2000
Renogram after 1 month → loss of at least 5% of renal function in 52% of patients
Shokeir A.A.

Lines Of Conservative Management
1. Pain relief. 2. Watchful waiting. 3. Role of antispasmodics. 4. Role of hydration.
Shokeir A.A.

Lines Of Conservative Management 1- Pain Relief
Traditional:
Morphine and pethidine

Recent:
NSAIDs

Other methods:
Intranasal desmopressin
Acupuncture
Shokeir A.A.

Lines Of Conservative Management 1- Pain Relief
NSAIDs In Renal Colic Mechanism of action

Arachidonic acid
COX

xxx

NSAIDs

PGs
Intrapelvic pressure RBF Diuresis Shokeir A.A.

Lines Of Conservative Management 1- Pain Relief NSAIDs In Renal Colic Advantages
Provide the same degree of pain relief as narcotics. Avoid the complications of narcotics (addiction, respiratory depression, mental changes, constipation).
Shokeir A.A.

Lines Of Conservative Management 1- Pain Relief
NSAIDs In Renal Colic Disadvantages

Decrease RBF by 35%
Consider renal function
Shokeir A.A.

Lines Of Conservative Management 1- Pain Relief
NSAIDs In Renal Colic Routes of administration IV, IM, Rectal, Oral, Sublingual. IV indomethacin is more effective than IM diclofenac. Rectal route is less effective than parentral route. Oral diclofenac prophylaxis prevents new episodes of renal colic. Sublingual piroxicam is as effective as parentral diclofenac.
Shokeir A.A.

Lines Of Conservative Management 1- Pain Relief
NSAIDs In Renal Colic Types of COX
Cox- 1:
Present in all cells. Constitutively expressed. Its inhibition gives the gastric and renal side effects.

Cox- 2:
Present in certain cells only. Responsible for inflammation. Its inhibition provides therapeutic effect.
Shokeir A.A.

Lines Of Conservative Management 1- Pain Relief
Intranasal desmopressin (minirin) (El Sherif et al, J Urol. 1995 “Qatar”) It causes significant decrease in renal colic. Mechanism is uncertain:  ?antidiuretic  ?relaxation of smooth muscle  ?central analgesic effect It needs further studies
Shokeir A.A.

Lines Of Conservative Management 1- Pain Relief
Acupuncture (Lee et al, J Urol, 1992)
Common in China.

As effective as conventional analgesics. Mechanism is uncertain ? Increased level of endogenous opiates which may modify sensory afferent impulses.
Shokeir A.A.

Lines Of Conservatives Management
2- Watchful waiting
KUB + Us → every 2 weeks. Intervention → 4-6 weeks.

Shokeir A.A.

Lines Of Conservative Management
3- Role of Antispasmodics

Not recommended.

Ureteric peristalsis needs to be encouraged and not discouraged.
Shokeir A.A.

Lines Of Conservative Management
4- Role of Hydration
Conventional teaching → push fluids?? Not logical:
Diuresis + obstruction → ↑ ↑pressure →:
 ↓ ↓ peristalsis → no stone passage.  ↑ ↑ pain.

Shokeir A.A.

When To Stop Conservatives Management
1. 2. 3. 4. 5.

Infection (fever, tachycardia, leukocytosis). Intractable pain > 72 hours. Stasis of the stone (4-6 weeks). Renal functional impairment. Socioeconomic reasons.

6.

Patient’s desire.

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Methods Of Treatment
Conservative ESWL Ureteroscopy PCNL Laparoscopy Open surgery
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ESWL Success Rate (%)
Proximal ureter ESWL In situ ESWL ESWL, with push-back ESWL, with ureteric stent ESWL, overall ≤ 1 cm 87 77 83 84 > 1 cm 76 65 76 72 Distal ureter ≤ 1 cm > 1 cm

85 76 No data No data 83 68 85 74

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ESWL Role Of Stent
General consensus
Does not improve the results (↓ motility).

Indications
Solitary kidney.

Severe degree of obstruction.
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ESWL Overall Experience
Advantages
Effective
Non- invasive Anaesthesia – independent

First line treatment in most cases

Disadvantages
Time consuming (several sessions + symptoms)

Operator- dependent
Machine- dependent
Shokeir A.A.

Methods Of Treatment
Conservative ESWL Ureteroscopy PCNL Laparoscopy Open surgery
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Ureteroscopy Technical Advances
Types: rigid, semirigid, flexible 4 - 9.8 F. Dilatation: 1/5 with 7.5 F.

Anesthesia: ?? sedoanalgesia with small instruments.
Hospital stay: ?? day-care setting.
Shokeir A.A.

Ureteroscopy Ureteric Stenting
Routine stenting
Not necessary Disadvantages
  

↑ ↑ operative time. ↑ ↑ symptoms (flank pain, LUTS). ↓ ↓ quality of life.

Indications
Difficult cases Prolonged procedures
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Ureteroscopy Methods Of Stone Extraction
Mechanical: Dormia, Forceps.
Intracoporeal lithotripters
US
Preumatic (lithoclast) EHL Ho: YAG laser
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Ultrasound
Mechanism: piezoelectrically generated fragmentation. US waves evoke mechanical stone Probe: rigid, reusable. Ureteroscope: rigid, semirigid.

Stone-free rate: 70 – 97%.
Safety: heat effects possible when irrigation speed is too low.

Disadvantage: not flexible.
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Pneumatic
Mechanism: compressed air-driven propelling metal projectile in handpiece evokes mechanical stone fragmentation. Probe: rigid and recently flexible, allow suction. Ureteroscope: rigid, semirigid, flexible. Stone-free rate: > 90%. Safety: mechanical perforation by direct contact.

Disadvantage: stone migration, needs fixation of the stone by basket.
Shokeir A.A.

Electrohydraulic
Mechanism: electric spark produces a plasma bubble and hydraulic shockwaves. Probe : flexible, life 30 sec. Ureteroscope: rigid, semirigid, flexible. Stone-free rate: > 90%. Safety: perforation by plasma bubble and heat effects possible. Disadvantage: higher risk of ureteral injury.
Shokeir A.A.

Ho: YAG laser [state of the art]
Mechanism: photothermal effect Probe : flexible , reusable. Ureteroscope: rigid, semirigid, flexible. Stone-free rate: - 97% in single session.
- 100% in staged sessions.

Safety: - Heat effects possible.
- Minimal tissue penetraction (0.5-1.0 mm).

Disadvantage: cost
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Ureteroscopy Overall Experience
Success rate: > 90% Complications:
Short-term: < 5%. Long-term: None.
Shokeir A.A.

ESWL Vs Ureteroscopy
Ureteroscopy Stone-free rate Time of treatment Complication rate Anesthesia Cost
Shokeir A.A.

ESWL Lower Longer Low Usually No Lower

Higher Shorter Low Usually Yes Higher

Methods Of Treatment
Conservative ESWL Ureteroscopy PCNL Laparoscopy Open surgery
Shokeir A.A.

Laparoscopic Ureterolithotomy
Centers capable of laparoscopy are also the same centers that show excellent results for less invasive modalities.

This, together with the learning curve associated with laparoscopy, is likely to restrict the overall expansion of this approach.
Shokeir A.A.

Open Ureterolithotomy
Rarely indicated manouever. Indicated in as a primary

Complications of other methods of stone removal Associated pathology e.g. ureteric stricture.
Shokeir A.A.

Management Of Ureteric Stones: An update
Special situations Children Pregnancy

Shokeir A.A.

Ureteric Stones In Children Special Considerations
Larger stones will pass easily through the ureter. Stenting prior to ESWL is not recommended. ESWL is not recommended in girls (damage of ovarian germ cells). ESWL requires anesthesia more frequently.
Shokeir A.A.

Ureteric Stones In Children
Treatment Options
Spontaneous passage is more frequent. 4 F pediatric ureteroscopes + laser→ safe & easy ureteroscopy As ESWL requires anethesia, the need to ensure success after one intervention favours ureteroscopy
Shokeir A.A.

Stones In Pregnancy
Physiological Considerations
Factors promoting stone formation
Hypercalciuria Hyperuricosuria

Factors inhibiting stone formation
↑ ↑ Urinary citrate ↑ ↑ Urinary magnesium Physiological respiratory alkalosis→ alkaline urine

Net result
Balance between opposing factors. The incidence of stones in pregnancy is not significantly different from that in nonpregnant women. Shokeir A.A.

Stones In Pregnancy
Physiological Consideration The physiological dilatation of the

upper urinary tract particularly on
the right side may provoke diagnostic confusion.
Shokeir A.A.

Stones In Pregnancy
Diagnosis
1. Gray-scale US

Not reliable because of physiological dilatation. 2. Doppler US Δ RI is of great help. 3. Three-shot IVP ? Radiation exposure? 4. Ureteroscopy Combines diagnostic accuracy and therapeutic potential.
Shokeir A.A.

Stones In Pregnancy Management
Treatment Of Renal Colic:
Opiates are the safest analgesics.
NSAIDs should be avoided.
Shokeir A.A.

Stones In Pregnancy Management
Most ureteric stones will pass spontaneously. Active management:
ESWL is contraindicated.
PCN and JJ stents→ encrustation (hyper calciuria) → change at 12-week interval. Ureteroscopy is the best.
Shokeir A.A.

Stones In Pregnancy Management
Ureteroscope
Shokeir, BJU, 1998
Rigid ureteroscopy is a safe and reliable method in the diagnosis and treatment of ureteric calculi during pregnancy
Shokeir A.A.

Harvest I
IVP is no longer the primary investigation in patients with suspected renal colic, however, it is still indispensable if endscopic or open intervention is decided. KUB and US with Doppler assistance are the procedures of choice in patients with history of stone disease.
Shokeir A.A.

Harvest II
NCCT is the investigation of choice in patients
with no history of stone disease or those with

atypical symptoms.
DUS is of particular importance in pregnant

women with suspected renal colic.
Shokeir A.A.

Harvest III
NSAIDs are as effective as pethidine and morphine in the relief of pain, however, clinicians should be aware of renal function. 80 % of ureteric stones causing renal colic will pass under conservative treatment.
If intervention is decided ESWL ureteroscopy are the treatment of choice.
Shokeir A.A.

or

Shokeir A.A.


								
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