MEDICAL STUDENT UROLOGICAL SURGERY
KNOWLEDGE FOR FINALS
|
,Final Year Surgery
Urology Surgery
Urolithiasis/Nephrolithiasis
Crystal aggregates forming in the collecting ducts.
Can lodge in multiple places but mostly commonly in 3 locations (PUJ, pelvic
brim crossing the iliac vessels and VUJ)
Most commonly calcium oxalate: idiopathic, due to concentrated urine, radio-
opaque.
Magnesium Ammonium phosphate: may form staghorn calculi, commonly
associated with UTI and proteus infection. Known as STRUVITE stones
Urate stones: Often due to Hyperuricemia i.e. gout and tumour lysis syndrome
in malignancy
Presentation
Pain (renal colic loin to groin)
Nausea and vomiting
Restless to alleviate pain (this is a good way to distinguish from peritonitis
because patients with peritonitis will be ridged and not wanting to move)
Obstruction of mid-ureter may mimic appendicitis/diverticulitis
Obstruction of lower-ureter may lead to symptoms of bladder irritability and
pain in the scrotum
Blatter/urethral obstruction = dysuria, strangury (urinary tenesmus) and
interrupted flow
Infection
Haematuria
Proteinuria
Sterile pyuria (leucocytes in the urine in the absence of demonstrable
infection)
Anuria
Investigations
Urine dip for haematuria, proteinuria and pyuria
MC+S (microscopy and culture)
Bloods FBC, U&E, Ca and PO4 and urate (urate stones, calcium stones etc.)
Imaging
80% of stones visible on a KUB XR (kidney, ureters bladder)
non-contrast KUB CT 99% visible gold standard
USS for viewing hydronephrosis
, Final Year Surgery
Treatment
Analgesia for renal colic (PR 100mg diclofenac or 75mg IM)
You could always prescribe morphine with naloxone on the drug chart to
cover the pain at all bases. With paracetamol PO or IV because paracetamol
and opioids are complimentary.
Anti-emetics ondansetron 4mg
IV fluids if unable to tolerate PO
Abx if infection present
Conservative
Increase fluid intake to increase likelihood of stone passing. <5mm in lower
1/3 of ureter 90-95% will pass spontaneously.
Medical
>5mm, not expelled yet but expected to pass, controlled symptoms and no
signs of sepsis.
>10mm, unlikely to pass, persistent obstruction, renal insufficiency, infection
Extracorporeal shockwave lithotripsy (ESWL). Outpatient shockwave therapy
directed at the region to break up the stone and have it pass spontaneously.
Ureteroscopy (laser beams used to break up stone)
Percutaneous nephrolithotomy (used where ESWL and uteroscopy are not
recommended >20mm and staghorn calculi). Nephroscope inserted into the
collecting system and removed actively.
Lap or open surgical excision is rare.
Emergency intervention with febrile obstruction via percutaneous nephrolithotomy
and IV antibiotics
Stones <5mm will usually pass spontaneously
Stones <2cm managed with lithotripsy
Stones <2cm in pregnancy females managed with Ureteroscopy
Complex renal calculi and staghorn calculi managed with percutaneous
nephrolithotomy
Calcium stones = Hypercalciuria due to high fluid intake, low animal protein
low salt diet and thiazide diuretics (increases reabsorption)
Oxalate stones = Cholestyramine use, pyridoxine
Uric acid stones = allopurinol and urinary alkalinisation with bicarbonates
Struvite stones = usually caused by an infection (UTI) and present as slightly
radio-opaque due to crystal formation
KNOWLEDGE FOR FINALS
|
,Final Year Surgery
Urology Surgery
Urolithiasis/Nephrolithiasis
Crystal aggregates forming in the collecting ducts.
Can lodge in multiple places but mostly commonly in 3 locations (PUJ, pelvic
brim crossing the iliac vessels and VUJ)
Most commonly calcium oxalate: idiopathic, due to concentrated urine, radio-
opaque.
Magnesium Ammonium phosphate: may form staghorn calculi, commonly
associated with UTI and proteus infection. Known as STRUVITE stones
Urate stones: Often due to Hyperuricemia i.e. gout and tumour lysis syndrome
in malignancy
Presentation
Pain (renal colic loin to groin)
Nausea and vomiting
Restless to alleviate pain (this is a good way to distinguish from peritonitis
because patients with peritonitis will be ridged and not wanting to move)
Obstruction of mid-ureter may mimic appendicitis/diverticulitis
Obstruction of lower-ureter may lead to symptoms of bladder irritability and
pain in the scrotum
Blatter/urethral obstruction = dysuria, strangury (urinary tenesmus) and
interrupted flow
Infection
Haematuria
Proteinuria
Sterile pyuria (leucocytes in the urine in the absence of demonstrable
infection)
Anuria
Investigations
Urine dip for haematuria, proteinuria and pyuria
MC+S (microscopy and culture)
Bloods FBC, U&E, Ca and PO4 and urate (urate stones, calcium stones etc.)
Imaging
80% of stones visible on a KUB XR (kidney, ureters bladder)
non-contrast KUB CT 99% visible gold standard
USS for viewing hydronephrosis
, Final Year Surgery
Treatment
Analgesia for renal colic (PR 100mg diclofenac or 75mg IM)
You could always prescribe morphine with naloxone on the drug chart to
cover the pain at all bases. With paracetamol PO or IV because paracetamol
and opioids are complimentary.
Anti-emetics ondansetron 4mg
IV fluids if unable to tolerate PO
Abx if infection present
Conservative
Increase fluid intake to increase likelihood of stone passing. <5mm in lower
1/3 of ureter 90-95% will pass spontaneously.
Medical
>5mm, not expelled yet but expected to pass, controlled symptoms and no
signs of sepsis.
>10mm, unlikely to pass, persistent obstruction, renal insufficiency, infection
Extracorporeal shockwave lithotripsy (ESWL). Outpatient shockwave therapy
directed at the region to break up the stone and have it pass spontaneously.
Ureteroscopy (laser beams used to break up stone)
Percutaneous nephrolithotomy (used where ESWL and uteroscopy are not
recommended >20mm and staghorn calculi). Nephroscope inserted into the
collecting system and removed actively.
Lap or open surgical excision is rare.
Emergency intervention with febrile obstruction via percutaneous nephrolithotomy
and IV antibiotics
Stones <5mm will usually pass spontaneously
Stones <2cm managed with lithotripsy
Stones <2cm in pregnancy females managed with Ureteroscopy
Complex renal calculi and staghorn calculi managed with percutaneous
nephrolithotomy
Calcium stones = Hypercalciuria due to high fluid intake, low animal protein
low salt diet and thiazide diuretics (increases reabsorption)
Oxalate stones = Cholestyramine use, pyridoxine
Uric acid stones = allopurinol and urinary alkalinisation with bicarbonates
Struvite stones = usually caused by an infection (UTI) and present as slightly
radio-opaque due to crystal formation
