Campbell-Walsh Urology, 11th Edition

PART IX

Urinary Lithiasis and Endourology

53

Strategies for Nonmedical Management of Upper Urinary Tract Calculi

Brian R. Matlaga; James E. Lingeman

Questions

  1. The best predictor of post–percutaneous nephrolithotomy (PNL) urosepsis is:
  2. preoperative bladder urine culture.
  3. intraoperative bladder urine culture.
  4. stone culture.
  5. preoperative blood culture.
  6. intraoperative blood culture.
  7. What is the risk of mortality from an untreated struvite staghorn stone?
  8. Less than 10%
  9. 10% to 30%
  10. 30% to 50%
  11. 50% to 70%
  12. Greater than 70%
  13. The increased risk of residual fragments after extracorporeal shockwave lithotripsy (SWL) of large-volume calculi is of particular importance for patients with stones composed of:
  14. brushite.
  15. uric acid.
  16. struvite.
  17. calcium oxalate monohydrate.
  18. calcium oxalate dihydrate.
  19. What is the single most important factor when choosing among SWL, ureteroscopic stone removal, and PNL for renal calculi?
  20. Stone composition
  21. Stone location
  22. Anatomic abnormalities
  23. Stone burden
  24. Body habitus
  25. What is the preferred treatment for a known brushite stone former harboring a lower pole renal calculus 25 mm in diameter?
  26. SWL
  27. SWL with ureteral stenting
  28. Flexible ureteroscopy with holmium laser lithotripsy
  29. PNL
  30. Laparoscopic pyelolithotomy
  31. What is the preferred initial treatment for staghorn calculi?
  32. SWL with ureteral stenting
  33. Flexible ureteroscopy with holmium laser lithotripsy
  34. PNL
  35. Extended pyelolithotomy
  36. Anatrophic nephrolithotomy
  37. Which of the following is the most difficult stone composition to fragment with SWL?
  38. Calcium oxalate dihydrate
  39. Calcium oxalate monohydrate
  40. Struvite
  41. Hydroxyapatite
  42. Uric acid
  43. What is the preferred treatment approach for a symptomatic 1.5-cm stone in a lower pole calyceal diverticulum?
  44. SWL
  45. Flexible ureteroscopy
  46. PNL
  47. PNL with fulguration of the diverticulum
  48. Laparoscopic diverticulectomy
  49. What is the preferred initial treatment for a 10-mm stone in the renal pelvis of a horseshoe kidney with minimal hydronephrosis?
  50. SWL
  51. Flexible ureteroscopy
  52. PNL
  53. Laparoscopic pyelolithotomy
  54. Symphysiotomy with pyelolithotomy
  55. What is the preferred treatment approach for a 10-mm renal calculus in a patient who weighs 375 lb?
  56. SWL
  57. Flexible ureteroscopy
  58. PNL
  59. SWL using the "blast path" technique
  60. Open surgery
  61. What is the preferred treatment option for a patient with a symptomatic 1.5-cm renal calculus and a coagulopathy?
  62. SWL
  63. SWL after administration of fresh-frozen plasma
  64. Indwelling ureteral stent
  65. Flexible ureteroscopy
  66. PNL
  67. Residual fragments after SWL have been associated with which of the following?
  68. Hypertension
  69. An increased rate of recurrent stones
  70. A decreased rate of recurrent stones
  71. Perinephric hematomas
  72. Hematuria
  73. What is the most sensitive test for identifying residual fragments after PNL?
  74. Nephrotomography
  75. Magnetic resonance imaging (MRI)
  76. Ultrasonography
  77. Noncontrast computed tomography (CT)
  78. Contrast-enhanced CT
  79. Factors affecting the probability of spontaneous passage of ureteral calculi include all of the following EXCEPT:
  80. stone size.
  81. stone location at presentation.
  82. stone composition.
  83. degree of hydronephrosis.
  84. duration of symptoms.
  85. Irreversible loss of renal function can occur within what time period when a completely obstructing ureteral stone is present?
  86. 1 week
  87. 2 to 4 weeks
  88. 4 to 6 weeks
  89. More than 6 weeks
  90. 3 months
  91. A first-time stone former is diagnosed with a 4-mm proximal ureteral calculus. The best initial management is:
  92. ureteroscopic laser lithotripsy.
  93. ureteral stent placement.
  94. SWL.
  95. expectant management.
  96. SWL with ureteral stent placement.
  97. Large-volume matrix calculi, which form as a consequence of urinary tract infection, are:
  98. effectively fragmented with SWL.
  99. best approached in a ureteroscopic fashion.
  100. generally sterile.
  101. radiopaque and well visualized on plain radiographic studies.
  102. most efficiently treated with PNL.
  103. Ureteral stent placement when SWL is performed for ureteral stones is appropriate for all of the following reasons EXCEPT:
  104. solitary kidney.
  105. relief of severe symptoms.
  106. enhancement of stone fragmentation.
  107. relief of obstruction.
  108. aid in localization of difficult-to-visualize stones.
  109. The preferred single agent for medical expulsive therapy for distal ureteral calculi is:
  110. nifedipine.
  111. tamsulosin.
  112. Solu-Medrol.
  113. ibuprofen.
  114. terazosin.
  115. The treatment modality associated with the greatest stone-free rates and the least morbidity for patients with distal ureteral stones of any size is:
  116. PNL.
  117. SWL.
  118. ureteroscopy.
  119. open ureterolithotomy.
  120. laparoscopic ureterolithotomy.

Answers

  1. c. Stone culture. The best predictor of post-PNL urosepsis is stone culture or renal pelvic urine culture results.
  2. b. 10% to 30%. The 10-year mortality rate of untreated staghorn stones was 28%, versus 7.2% in patients treated with surgery.
  3. c. Struvite.Struvite stones must be removed completely to minimize the risk of continued urea-splitting bacteriuria.
  4. d. Stone burden. Stone burden (size and number) is perhaps the single most important factor in deciding the appropriate treatment modality for a patient with kidney calculi.
  5. d. PNL.The Lower Pole Stone Study Group compared ureteroscopy and PNL for patients with 10- to 25-mm lower pole stones and found a significant difference in stone clearance, with only 40% of the ureteroscopic cohort stone free at 3 months versus 76% of the PNL cohort.
  6. c. PNL. The management of staghorn stones with a combined approach must be viewed as primarily percutaneous, with SWL being used only as adjunct to minimize the number of accesses required.
  7. b. Calcium oxalate monohydrate. Cystine and brushite are the stones most resistant to SWL, followed by calcium oxalate monohydrate. Next, in descending order, are hydroxyapatite, struvite, calcium oxalate dihydrate, and uric acid stones.
  8. d. PNL with fulguration of the diverticulum. The percutaneous approach for the management of patients with calyceal diverticular stones provides the patient with the best chance of becoming stone and symptom free.Fulguration of the diverticulum will reduce the risk of recurrence of the diverticulum.
  9. a. SWL.SWL can achieve satisfactory results in properly selected patients, such as those with small stones (< 1.5 cm) in the presence of normal urinary drainage. For larger stones, or when there is evidence of poor urinary drainage, PNL should be used as the primary approach.
  10. b. Flexible ureteroscopy.Retrograde ureteroscopic intrarenal surgery may be the preferred modality of treatment for morbidly obese patients when the stone burden is not excessively large.
  11. d. Flexible ureteroscopy. When anticoagulation cannot be temporarily discontinued, the use of ureteroscopy in combination with holmium laser lithotripsy is preferred.One study reported that even when patients' coagulopathies were not fully corrected the stones could be successfully treated with no increase in hemorrhagic complications.
  12. b. An increased rate of recurrent stones.At follow-up (1.6 to 85.4 months), 43% of the patients with residual fragments had a significant symptomatic episode or required intervention.
  13. d. Noncontrast computed tomography (CT).Although flexible nephroscopy is often considered the "gold standard" for assessing residual stones after PNL, the routine use of flexible nephroscopy has been challenged by studies showing the high sensitivity of noncontrast CT in detecting residual stones. Noncontrast CT had 100% sensitivity for detecting residual stones after PNL in 36 patients evaluated by both CT and flexible nephroscopy.
  14. c. Stone composition.One study analyzed 75 patients with ureteral calculi and found that the interval to stone passage was highly variable and dependent on stone size, location, and side. Stones that were smaller, more distal, and on the right side were more likely to pass spontaneously. In another study, duration of symptoms before presentation was the most influential factor, followed by the degree of hydronephrosis.
  15. b. 2 to 4 weeks.Even with complete ureteral obstruction, irreversible loss of renal function does not occur for more than 2 weeks but can progress to total renal unit loss at up to 6 weeks.
  16. d. Expectant management. The majority of ureteral stones less than 5 mm will pass spontaneously and therefore can be treated with expectant management.
  17. e. Most efficiently treated with PNL. Matrix stones are most effectively treated with PNL.SWL is usually ineffective because of the stone's gelatinous nature, and ureteroscopy may be compromised by the large volume of stone material present.
  18. c. Enhancement of stone fragmentation.Although early reports supported the routine use of a ureteral stent to bypass ureteral stones before SWL, data analyzed by the American Urological Association Ureteral Calculi Guidelines Panel showed no improvement in fragmentation with stenting, and therefore routine stent placement before SWL was discouraged. However, ureteral stent placement is appropriate for other indications, such as management of pain, relief of obstruction, and stones that are difficult to visualize, and is mandatory in a patient who has a solitary obstructed kidney.
  19. b. Tamsulosin. Tamsulosin, a selective α-adrenergic blocker, is the preferred agent for medical expulsive therapy, owing to its reported efficacy and superior side effect profile.
  20. c. Ureteroscopy.The stone-free rate for distal ureteral stones approached with ureteroscopy was 91% in the American Urological Association/European Association of Urology Ureteral Stones Guidelines document, an outcome superior to SWL.

Chapter review

  1. Determinants of poor stone clearance rates after SWL include large renal calculi, lower pole or obstructed portions of the collecting system, very hard stones, and obesity.
  2. Most calyceal stones in the absence of intervention are likely to increase in size and cause pain or infection.
  3. If left untreated, staghorn calculi are likely to be associated with a progressive decrease in renal function.
  4. Patients with cystinuria are more likely to have decreased renal function than other stone formers.
  5. There is a linear correlation between Hounsfield units (density) and success of SWL.
  6. Complete stone clearance from lower pole calyces is less likely than from other calyces for reasons that are not totally clear.
  7. Spontaneous passage of a distal ureteral stone is more likely than that of a proximal ureteral stone.
  8. For patients with proximal ureteral stones, there is no difference between treating the stone in situ or pushing it back into the renal pelvis when utilizing SWL.
  9. In humans, there is no clear time threshold for irreversible damage in complete ureteral obstruction. It is clear, however, that patients with compromised vasculature, decreased renal reserve, poor nutrition, and other comorbid diseases such as diabetes, tolerate obstruction less well than patients with normal kidneys. Most agree that a significantly obstructing stone should not be allowed to persist beyond 2 to 4 weeks.
  10. Untreated staghorn calculi are associated with recurrent urinary tract infections, urosepsis, renal function deterioration, and increased mortality.
  11. Renal stones < 1 cm are best treated with SWL or ureterorenoscopic extraction; stones between 1 and 2 cm which are not in the lower pole are best treated with SWL or PNL; stones > 2 cm are best treated with PNL.
  12. Matrix renal stones are best removed with PNL.
  13. Alpha blockers increase the rate of spontaneous passage of ureteral stones. Tamsulosin, a selective α-adrenergic blocker, is the preferred agent for medical expulsive therapy.
  14. Bacteria may reside deep in the stone and may be impossible to eradicate without complete stone removal.
  15. Medications responsible for producing stones include ephedrine, indinavir, triamterene, magnesium trisilicate, ciprofloxacin, and sulfa drugs.
  16. The best predictor of post-PNL urosepsis is stone culture or renal pelvic urine culture results.
  17. Stone burden (size and number) is perhaps the single most important factor in deciding the appropriate treatment modality for a patient with kidney calculi.
  18. Cystine and brushite are the stones most resistant to SWL, followed by calcium oxalate monohydrate.
  19. The percutaneous approach for the management of patients with calyceal diverticular stones provides the patient with the best chance of becoming stone and symptom free.
  20. When anticoagulation cannot be temporarily discontinued, the use of ureteroscopy in combination with holmium laser lithotripsy is preferred.
  21. The majority of ureteral stones less than 5 mm will pass spontaneously.
  22. Pregnant women who require admission and require treatment for renal colic have a greater risk of preterm delivery.
  23. Pregnancy induces a state of absorptive hypercalciuria and mild hyperuricosuria that is offset by increased excretion of urinary inhibitors such as citrate and magnesium, as well as increased urinary output.
  24. SWL is now known to induce acute structural changes in the treated kidney in most, if not all, patients. The insult is primarily a vascular injury.
  25. Uncorrected coagulopathy and an active, untreated urinary tract infection are two absolute contraindications to PNL.
  26. Physiologic solutions should be used for irrigation during PNL to minimize the risk of dilutional hyponatremia in the event of large-volume extravasation.