Urology & Nephrology Q1

Renal Stones

 

Clinical Presentation

Patients experiencing renal colic classically present with severe, acute flank pain that radiates to the ipsilateral groin. However, it is important to note that the radiation of pain may not always be present, and some individuals may remain asymptomatic. The pain can be accompanied by other symptoms such as:

1. Nausea and vomiting

2. Increased urinary frequency/urgency.

Risk Factors

. Several risk factors can predispose individuals to develop renal colic, including:

. Dehydration

. High intake of salt

. Male sex

Investigations

In the event of suspected renal colic, the following investigations can be undertaken to confirm the diagnosis:

i. Complete Blood Test: This can sometimes show raised white blood cell (WBC) count.

ii. Urinanalysis: It is not uncommon to find blood in the urine.

iii. Non-Contrast CT-KUB (Computed Tomography of the Kidney, Ureters, and Bladder): This should be performed within 24 hours to confirm the diagnosis. It is the gold standard for diagnosing kidney stones and can provide detailed information on the size and location of the stone(s).

Managing Kidney Stones

In the management of renal stones, it is important to approach treatment based on the size of the stone detected, among other specific circumstances. Below are the general guidelines based on stone size:

 

Stone Size Recommended Treatment
Smaller than 0.5 cm (< 5 mm) Increase fluid intake to encourage natural expulsion through urine
Between 0.5 cm and 2 cm 1. ESWL (Extracorporeal Shock Wave Lithotripsy) – Preferred method
2. Ureteroscopy with a dormia basket for manual stone removal
Larger than 2 cm Percutaneous Nephrolithotomy (PCNL) for stone removal

 

Special Considerations

Case 1:

i. In cases where the patient has only one functioning kidney (due to the history of the removal of the other) and presents with any size of stone, dilatation of the pelvicalyceal system (PCS), possibly accompanied by anuria or fever:

ii. Immediate action is necessary to prevent obstructive uropathy.

iii. Initially, Percutaneous Nephrostomy should be performed to decompress the PCS and preserve the remaining kidney.

iv. If Percutaneous Nephrostomy is not an option, inserting a ureteric stent to facilitate urine drainage should be considered.

 

Case 2:

i. In the scenario where a patient with two functioning kidneys develops Acute Kidney Injury (AKI), indicated by impaired urea and creatinine levels, fever, and hydronephrosis in conjunction with stones:

ii. Immediate intervention is required to prevent obstructive uropathy regardless of stone size.

iii. Percutaneous Nephrostomy is advisable to instantly and temporarily relieve the renal collecting system.

 

Clarification on Terms

Percutaneous Nephrostomy: Involves creating a stoma with a catheter to the kidney to drain obstructed fluid and alleviate pressure.

Percutaneous Nephrolithotomy: Entails the percutaneous removal of urinary stones larger than 2 cm using a scope.

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