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URETERIC CALCULI
- 1. RECENT ADVANCES IN MANAGEMENTOF URETERIC CALCULI -DR.NAVYA TEJA
- 2. URETERIC CALCULI • ALWAYSOF RENAL ORIGIN. • CAN IMPACTED AT VARIOUS NARROW JUNCTIONS. • NATURE OF THE STONES SIMILAR TO RENAL STONES.
- 3. TYPES OF CALCULI CALCIUMOXALATE STONES (75%) PHOSPHATE STONES URIC ACID STONES STRUVITE STONES CYSTINE STONES XANTINE STONES
- 4. CLINICAL FEATURES • MOST OFTHEM PRESENT BETWEEN THE AGES 30 & 50 • MALE PREPONDERANCE • PAIN- COLICKY TYPE, RADIATES FROM LOIN TO GROIN OFTEN TO THE TIP OF GENITALIA • NAUSEA ,VOMITTING, SWEATING DUE TO REFLUX PYLOROSPASM • HEMATURIA,DYSURIA,FREQUENCY,STRANGURY • TENDERNESS IN ILIAC FOSSA ( NO REBOUND TENDERNESS)
- 5. INVESTIGATIONS • NON-CONTRAST CTSCAN- DIAGNOSTIC • X-RAY KUB • URINE ROUTINE & MICROSCOPY,C/S • SERUM UREA & CREATININE • SERUM CALCIUM & URIC ACID • IVU
- 6. DIFFERENTIAL DIAGNOSIS APPENDICITIS CHOLECYSTITIS OVARIAN CYST MESENTERIC ADENITIS RUPTUREDECTOPIC GESTATION TUBO-OVARIAN DISEASE
- 7. INDICATIONS FOR CONSERVATIVEMANAGEMENT • Single stone less than or equal to 5 mm • Stone in lower one third of ureter • Ureter is undilated • Evidence of downward movement
- 8.
- 9. EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY(ESWL) •NON-INVASIVE • SHOCKWAVES GENERATED OUTSIDE THE BODY & FOCUSSED ON THE STONES • DIFFERENT METHODS INCLUDE SPARK GAP,ELECTROMAGNETIC,PIEZOELECTRIC & MICROEXPULSIVE • SHOCK WAVES GENERATED BY SPARK-GAP METHOD NEED TO BE COORDINATED WITH ECG TO PREVENT CARDIAC ARRHYTHMIAS. • STONES UPTO 1.5 CM • STEINSTRASSE
- 11. INDICATIONS FOR ESWL •INDIVIDUALS WHO WORK IN PROFESSIONS IN WHICH UNEXPECTED SYMPTOMS OF STONE PASSAGE MAY PROMT DANGEROUS SITUATIONS. • INDIVIDUALS WITH SOLITARY KIDNEYS. • PATIENTS WITH HYPERTENSION ,DIABETES & OTHER MEDICAL CONDITIONS THAT PREDISPOSE TO RENAL INSUFFICIENCY
- 12. ABSOLUTE CONTRAINDICATIONS FOR ESWL ACUTE UTI UNCORRECTEDBLEEDING DISORDERS PREGNANCY UNCORRECTED OBSTRUCTION DISTAL TO THE STONE
- 13. RELATIVE CONTRAINDICATIONS FOR ESWL • MORBIDOBESE PATIENTS • PATIENTS WITH ORTHOPEDIC OR SPINAL DEFORMITIES • RENAL ECTOPIA • POORLY CONTROLLED HYPERTENSION • RENAL INSUFFICIENCY PREEXISTING CARDIAC & PULMONARY ARE NOT CONTRAINDICATIONS
- 14. COMPLICATIONS OF ESWL •BACTERIURIA • HEMATURIA • PARENCHYMAL HEMORRHAGE • PERIRENAL HAEMATOMA MORE THAN ONE TREATMENT SESSION MAY BE NEEDED TO TREAT THE STONE
- 15. URETEROSCOPY • Upper urinarytract endoscopy performed most commonly with endoscope passed through the urethra,bladder & then directly into upper urinary tract.
- 17. DIAGNOSTIC INDICATONS OF URETEROSCOPY ABNORMAL IMAGEFINDNGS- FILLING DEFECT OBSTRUCTON – DETERMINATION OF ETIOLOGY LOCALISING THE SOURCE OF POSITIVE URINARY CYTOLOGY RESULTS EVALUATION OF URETERAL INJURY SURVEILLANCE WITH KNOWN HISTORY OF UROTHELIAL MALIGNANCY
- 18. THERAPEUTIC INDICATIONS FOR URETEROSCOPY ENDOSCOPIC LITHOTRIPSY RETROGRADE ENDOPYELOTOMY INCISION OF URETERAL STRICTURES IMPROVEMENT OF CALYCEAL DRAINAGE TREATMENT OF MALIGNANT URTHELIAL TUMOURS TREATMENT OF BENIGN TUMOURS & BLEEDING LESIONS
- 19. INDICATIONS FOR DORMIABASKETING • STONE IN LOWER ONE THIRD • STONE LESS THAN 10MM SIZE • STONE BELOW PELVIC BRIM • SINGLE STONE
- 20. CONTRAINDICATIONS FOR URETEROSCOPY UNTREATEDUTI ENDOSCOPY WITHOUT APPROPRIATE ANTIBIOTIC COVERAGE UNCORRECTED BLEEDING DISORDERS
- 21. COMPLICATIONS OF URETEROSCOPY •INJURY TO URETERIC MUCOSA/WALL • URETERIC PERFORATION & EXTRAVASATION • AVULSION OF URETER
- 22. PERCUTANEOUS NEPHROLITHOTOMY • TECHNIQUEUSED TO TREAT LARGE STONES IN RENAL PELVIS & CALYCES,SOMETIMES IN PROXIMAL URETER • A TRACT IS ESTABLISHED INTO RENAL COLLECTING SYSTEM USING USG/FLUOROSCOPIC GUIDANCE • A SERIES OF DILATORS IS USED FOLLOWED BY PLACEMENT OF WORKING SHEATH INTO THE COLLECTING SYSTEM THROUGH WHICH STONE IS VISUALISED & FRAGMENTED ( USING USG/LASER/LITHOCAST) • NEPHROSTOMY TUBE IS LEFT IN THE KIDNEY FOR 24-48 HRS
- 24. PCNL-INDICATIONS • OBSTRUCTION- Anatomicalobstruction such as PUJ obstruction,calyceal diverticula,ureteric stricture preventing the passage of stone fragments after ESWL • Obese patients in whom ESWL is contraindicated • LOWER CALYCEAL STONES • Struvite stones- need to be removed completely because of associated infection • Calcium oxalate monohydrate & cystine stones- difficult to fragment using ESWL • ANTEGRADE URETERAL STENTING
- 25. PCNL- COMPLICATIONS • INJURYTO SPLEEN,PLEURA & COLON • HEMORRAGE FROM RENAL PARENCHYMA,SOMETIMES EVEN FROM RENAL VESSELS ( EMBOLISATIONNEPHRECTOMY) • SEPSIS • EXTRAVASATION DUE TO RUPTURE OF COLLECTING SYSTEM • RETAINED STONE FRAGMENTS • OPEN SURGERY
- 26. MEDICAL MANAGEMENT OF STONES GOAL ISTO PREVENT FORMATION OF NEW STONES/FURTHER GROWTH OF EXISTING STONES HIGH FLUID INTAKE TO PREVENT SUPERSATURATION OF URINE AIM OF PRODUCING ATLEAST 2.5L OF URINE IN 24 HRS
- 27. THIAZIDE DIURETICS-REDUCE URINARYCALCIUM EXCRETION BY INCREASING FRACTIONAL CALCIUM REABSORPTION IN DISTAL NEPHRON. ORTHOPHOSPHATES –USED TO DECREASE CALCIUM EXCRETION & INCREASE INHIBITOR ACTIVITY
- 28. MANAGEMENT BASED ON TYPE OFSTONE • FOR URIC ACID STONES- LOW PURINE DIET,ALKALISATION OF URINE & HYDRATION. ALLOPURINOL • FOR STRUVITE STONES-LOW CALCIUM & PHOSPHORUS DIET • FOR CYSTEINE STONES-LOW METHIONE DIET,ALKALISATION OF URINE,CYSTEINE COMPLEXING AGENTS- D-PENCILLAMINE & ALPHA MERCAPTOPROPIONYL GLYCINE
- 29. MEDICAL EXPULSIVE THERAPY ALPHA ADRENOCEPTOR ANTAGONISTS CALCIUMCHANNEL BLOCKERS CORTICOSTEROIDS
- 30. ALPHA ADRENOCEPTOR ANTAGONISTS • TAMSULOSIN (MC),ALFUZOCIN,TERAZOCIN •CAPABLE OF DECREASING THE RESTING TONE OF THE URETER,INTERFERING WITH URETERIC CONTRACTIONS,THEREBY DECREASING THE FREQUENCY OF PERISTALTIC CONTRACTIONS • SEVERAL STUDIES D DEMONSTRATED THAT ALPHA BLOCKERS EXPEDITE STONE PASSAGE,DECREASE PAIN & HENCE DECREASE ANALGESIC REQUIREMENTS
- 31. CALCIUM CHANNEL BLOCKERS NIFIDIPINE– MC BETTER RESULTS WHEN GIVEN ALONG WITH CORTICOSTEROIDS STUDIES COMPARING NIFIDIPINE AGAINST TAMSULOSIN SHOW TAMSULOSIN MORE EFFICACIOUS
- 32. CORTICOSTEROIDS • REDUCES STONEINDUCED EDEMA & HENCE ALLOW CALCULUS TO PASS • STEROIDS COMBINED WITH AN ALPHA BLOCKER PROVED MORE EFFICACIOUS THAN EITHER STEROID OR ALPHA BLOCKER ALONE . • STUDIES COMPARED TAMSULOSIN,DEFLAZOCORT,COMBINATION OF BOTH,ANALGESICS SHOWS RATE OF EXPULSION 60%,37.5%,84.8%,33.3%