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Common Urological Problems

Urinary Stone Disease - Special Situations

  • - General Urology - Common Urological Problems - Urinary Stone Disease
  • Jul 25, 2010
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Tags: | abdominal pain | asymptomatic hematuria | calcium | calcium nephrolithiasis |

A. RENAL TRANSPLANTATION
Urinary stones associated with renal transplantation are rare. Perirenal nerves are severed at the time of renal harvesting. Classic renal colic is not found in these patients.

The patients usually are admitted with the presumptive diagnosis of graft rejection. Only after appropriate radiographic and ultrasonic evaluation is the correct diagnosis made (Figure 16–9).

B. PREGNANCY
Renal colic is the most common nonobstetric cause of acute abdominal pain during pregnancy (Figure 16–10).

Despite marked hypercalciuria associated with pregnancy, calculi are relatively rare, with an incidence approximating 1:1500 pregnancies.  Women with known urinary stone disease do not have an increased risk of stones during pregnancy.  The increased filtered load of calcium,  uric acid, and sodium from the 25–50% increase in glomerular filtration rate associated with pregnancy has been thought to be a responsible factor in stone development.

The fetus demands special considerations regarding the potential dangers of radiation exposure (especially during the 1st trimester),  medications,  anesthesia,  and surgical intervention.  About 90%  of symptomatic calculi present during the 2nd and 3rd trimesters. Initial investigations can be undertaken with renal ultrasonography and limited abdominal x-rays with appropriate shielding.  Treatment requires balancing the safety of the fetus with the health of the mother.  Temporizing measures to relieve upper-tract obstruction with a double-J ureteral stent or a percutaneous nephrostomy tube can be performed under local anesthesia.

Urinary Stone Disease

Urinary Stone Disease

Treatment usually can be delayed until after delivery.

C. DYSMORPHIA
Patients with severe skeletal dysmorphia that is either congenital (spina bifida, myelomeningocele, cerebral palsy) or acquired (arthritis, traumatic spinal cord injuries) and concurrent urinary calculi represent a unique clinical situation requiring special considerations (Figure 16–11).  These skeletal abnormalities may preclude appropriate positioning for ESWL or percutaneous approaches. Calculi on the concave side in a patient with severe scoliosis may eliminate percutaneous puncture access between the rib and the posterosuperior iliac spine. Retrograde manipulations may need to be performed with flexible endoscopes due to marked contractures,  making conventional dorsal lithotomy positioning impossible.  Many such patients have undergone supravesical urinary diversion,  so that retrograde access may be limited.  Risks that need to be addressed include hypercalciuria associated with immobilization, relative dehydration due to patients’ or attendants’ attempts to reduce urinary output into external collecting devices, and the potential inability to drink without assistance.

A full metabolic evaluation is even more important because these social and physical restrictions may be difficult or impossible to remedy.

D. OBESITY
Obesity is a risk factor for the development of urinary calculi.  Surgical bypass procedures can cause hyperoxaluria.

Massive weight gain or loss also may precipitate stone development. 

Obesity limits diagnostic and treatment options. A large pannus may limit the physical examination and misguide incisions.  Ultrasound examination is hindered by the attenuation of ultrasound beams.  CT, magnetic resonance imaging,  fluoroscopy tables,  and lithotripters all have weight limitations,  and patients weighing >300 lb may be unsuited for diagnosis and treatment with these resources. Standard lithotripters have focal lengths <15 cm between the energy source and the F2 target, frequently making treatment of obese patients impossible. A large anterior pannus limits prone positioning on lithotripters. Standard Amplatz nephrostomy sheaths may not be long enough to enter the collecting system. Such sheaths may need to be advanced well below the skin. A preplaced heavy suture eases removal of such sheaths.

image Figure 16–9.  Scout abdominal radiograph demonstrating renal calculus in a renal transplant in the right iliac fossa. Note native renal vasculature with marked calcifications secondary to malignant diabetes mellitus.

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Risks of anesthesia are increased and special high-pressure respirators may be required if patients are placed in a prone position for a percutaneous procedure. Careful positioning for open procedures helps to reduce the likelihood of crush injuries and associated rhabdomyolysis.  These patients are at increased risk of anesthetic complications.

image Figure 16–10.  Scout radiograph demonstrating left renal calculus with double-J ureteral stent in place.
Skeletal fetal structures can be appreciated in this pregnant patient.

Postoperative prophylaxis for thromboembolic complications should be considered.

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