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HOLLYWOOD

UROLOGY
Monash Avenue, Nedlands
WA 6009

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

PATHOPHYSIOLOGY AND MANAGEMENT OF


URETERAL & RENAL STONE DISEASE

R.B THOMAS FRACS (UROL)


Renal stone disease is a common source of morbidity in the community. 15 - 20 % of the population
may experience at least one episode of renal colic in their lifetime. This discussion aims to examine
some of the pertinent aspects of diagnosis and treatment along with a consideration of the
pathophysiology of stone formation.
Pathophysiology of stone formation;
Theories
foreign body.

1) Nucleation - Formation initiated by crystal or

2) Stone matrix - organic matrix=


serum&urinary proteins.( globulins,
mucoproteins, Gags, Matrix substance A)
3) Inhibitors of crystallisation - Mg,
pyrophosphate, citrate, phosphocitrate
,mucoproteins, RNA , Gags & various peptides.
Generalised theory incorporates all 3 theories; ie urinary
supersaturation, lack of inhibitors ,
Anatomical abnormalities

[nucleating material]

chronic infection & enhanced crystal deposition.

Where does stone formation occur?


1) Ca++ deposition :- basement membrane collecting tubules &papillae = Randalls
plaques
obstruction,breakdown
membrane
2) linear ppts of Ca++ within renal lymphatics
between lymphatics & collecting tubules. (theory of Carr).
3) Intratubular:- amorphous necrotic calcific cellular debris or organised microcalculi
(intranephronic calculosis).
Factors assoc;
a) personal/family hx
b) inflammatory bowel/short bowel
c) recurrent UTI's
d) immobilisation
e) inherited; RTA, cystinuria, hypercalciuria(Auto dom)
f) medications;
acetazolamide(glaucoma) : (Ca stones)
antacids: x's Ca++,(+ silica rich- rare silica calculi!)
Ascorbic acid> 2gm/day ur :oxalate CaOx stones
Vit D Hypercalcaemia
allopurinol : Xanthine stones(rare)
Drugs urinary pH : Uric acid calculi
Orthophosphates worsen struvite stones

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

Thiazides worsen uricosuria.


Symptoms of stone disease.
Renal/Ureteric colic - pain is severe with colicky exacerbations.
Pain anywhere along loin to groin distribution.
Signs.= any degree of haematuria. Pyrexia if infected.

Distal stones, pain often radiates to testis and may be the only sx.
Nonrenal sx
due to autonomic x innervation via coeliac ganglia nausea, ileus etc.
symptoms are highly variable. may be no Sx-persisting haematuria/UTI.Persisting UTI often assoc
with struvite calculi.
Lab Findings

urinalysis, pyuria, bacteriuria, pH

Radiography: > 90% all stones radio-opaque


Ca PO4 - apatite/brushite = most dense
Ca Ox
MgAmmoniumPO4 (struvite)
Cystine ('ground glass')
uric acid & pure matrix are completely radiolucent
Common Differentials; mesenteric nodes
calcified rib cartilage
gallstones
foreign bodies (medication)
phleboliths
calcium stone fragility roughly proportional to density;
22
Relative densities
CaPO4
CaOx 10.8
Mgam PO4
4.1
Cystine
3.7
Uric acid
1.4
Xanthine
1.4

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

IVU - look at the films in series; plain film, nephrogram, excretory film,postmicturition film for bladder etc. Oblique films may reveal distal stones.
Perirenal/Periureteral extravasation in high grade obstn. due to forniceal tear. see
contrast in Gil-Vernets plane('safety
valve to decompress system')
U/S:- May be used as first line Ix or when IVU not possible. Also to see upper tract
dilatation.(also in pregnancy and renal failure.)
CT:- staghorn anatomy. ? stone in ant or posterior calyx?

Types of stones;
Calcium
CaPO4 & CaOx: CaOx - The sole or major component in 80%. In mono/dihydrate
form or both. CaPO4 - Apatite (more
common Ca10[PO4]6[OH]2)
or Brushite (unusual
CaHPO4.2H2O).
In normal ionic concentrations both are highly insoluble.
epidemiology; 30-50 yrs highest
M:F 3:1
dehydration
sedentary
1st stone, 60% 2nd stone in 7 years(selective medical
Rx may recurrence rate)
re cost
Diagnostic evaluation of Ca++ stone former; Philosophical Viewpoint
effectiveness; If you do investigate then the following
schema is useful;
Screening following a single calcium stone
-: fbp, u+e's,urinalysis +culture. If cost is no object then
obtain 24 hr urinecollection
(Ca++,PO4=,uric,acid,citrate,oxalate,creatinine)
Complete evaluation; for 'metabolically active' stone
formers. (protocol of Pak 1980, although other protocols in use). Can be done as in or
outpatient.
Hypercalciuric classification;
1) absorptive
2) resorptive
3) renal
> 300mg/day is considered abnormal on unrestricted diet.
av diet = 500 - 1000 mg/day - absorpion mostly
duodenum/upper jejunum - absn mostly Vit D dependent
( some by diffusion)
1) Absorptive: - most common in CaOx stones (50 - 60 %)
altered Intestinal response to Vit D
To N with fasting
excrn may fall when diet restricted to
150 mg/day.
Rx.

Dietary Ca++ & Na++ (Na aids Ca abspn)


Na++ 100meq/day

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

Ca++ 800meq/day
limit carbohydrates & protein, encourage fibre rich
foods with phytic acid (inositol hexaPO4) - binds dietary
Hydration:2 -3 L/day. no colas,fruit juices/tea (oxalate)

Ca++.

Cellulose PO4:- Ca++/Na++ ion exchange resin.


OrthoPO4
2) Renal:- 10% stone formers. Cause unknown but known
absn & resbn.
tubular defect. Ca++ loss-- PTH + Vit D -++
Rx. Thiazides. Ca excretion. Max effect in 1/52 effect
sustained.

Ca++ respn in distal tubule.


can be used to Rx absorptive and renal.
Ortho PO4 in difficult 20 HyperPTH.

3)Resorptive:- relatively uncommon. HyperPTH. 4 - 6%


of all pts. Also cushings, carcinoma, myeloma, immobilisation.
Rx. of the underlying pathology.

What if normocalciuric? - 10 glasses H2O/day. Try thiazides +/- citrate


Other disorders assoc with calcium stones;
1) Sarcoidosis:- Ca PO4 > Ox. Intestinal sensitivity to Vit D.
Rx: Steroids.
2) RTA:- syndrome characterised by persistent acidosis.
3 types; Type 1= 'Distal' only type forming stones.
Auto dom/70% F/70% form stones.
'complete'form=
serum HCO3- & K+, Urinary citrate Alk phos
can't acidify urine below pH 6.0. freq pure CaPO4
nephrocalcinosis
Incomplete penetrance = form stones, not acidotic.
acidify to pH 5.4.
Rx. fluids, NaHCO3-, citrate. monitor urinary citrate
3)Hyperoxaluria..normally poorly absorbed (25%).
typical diet= 70 - 920 mg/day
vegetarian= 80 - 2000mg/day
1 = glyoxalate carboligase
Types; 10 rare. types 1&2.
2 = D-glycerate dehydrogenase.
Dx-> >100mg/day urinary excretion. Rx pyridoxine.
restrict oxalate. transplantation.
Ingestional; asc acid , ethylene glycol.
Enteric; inflammatory bowel disease, small bowel
bypass. x's fatty acids bind Ca++ in gut, thus free

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

oxalate
also bile salts/fatty acids
permeability.

mucosal

Rx. low oxalate + fat diet.


ileal bypass.

Ca++.cholestyramine.reverse

4)Hyperuricosuria
20% of oxalate stones. Uric acid crystals act as nucleus.
may counter inhibitory substances.
5)Heterozygous Cystinuria high incidence in CaOx stones.
F 17.1%
M 11.8%
6)Hypocitraturia
possible factor in 19 - 63% nephrolithiasis. citrate
complexes urinary Ca++.

CYSTINE STONES.
(homozygous Cystinuria). rare. auto recessive.impaired
reabsorption from renal tubules of the dibasic amino acids.
cystine, lysine, ornithine, arginine.
1/20,000
1 - 4 % of all calculi
Nomal excretion
100mg/day
Heterozygous form 100 - 300mg/day
Homozygous form 500 - 1000mg/day
solubility@ pH 4.5 - 7.0 =300 - 400mg/l. Thus only homozygotes
form stones.
Dx. urine=acidic. classic hexagonal crystals. qualitative
nitroprusside test= quick. If +ve 24hr quantitation.
X-rays= laminated 'ground glass' appearance.
total cystine in urine

Rx. 3 principles.1)
2)

solubility in urine

3)

urinary excretion cystine.

Struvite calculi;
"triple PO4" stones. struvite= geologic term (MgNH4PO4 . 6H2O).
? whether stone or infection comes first?
assoc with UTI with urea splitting organisms*.urine must be
supersaturated with Mg, NH4, PO4, apatite. (supersaturation +
(urea) = stones).
* proteus, pseudomonas, klebs, staph.
60 - 90 % staghorns assoc solely with urea splitters.
in urinary diversion + chronic catheters/spinal injuries/
neurogenic bladders.
Dx. msu, x-rays - often poorly mineralised, so may be faint.

alkaline pH

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

Rx.

of recurrent UTI, obstruction, pain.


dissolution/lithotripsy/removal.

Staghorns must be treated. 10yrs - 50 -70% disease specific


survival. 50% renal loss rate.
surgery to:

1) remove calculi
2)repair anatomic abnormalities
3)eradicate infection
4)preserve renal tissue
5)prevent recurrent infection.

Surgical options;

a)nephrectomy
b)partial nephrectomy
c)nephrolithotomy - intersegmental
- extended
- simple
d)PCN
e)ESWL

residual stone rate 5 -30% depending on technique.

Stone dissolution.
hemiacidrin = citric acid, anhydrous-d-gluconic magnesium
hydroxycarbonate, mg citrate, CaCO3.
acts by Ion exchange;

can be infused by nephrostomies. sterilise urine. prove


system for 24 hrs; if leakage or pain occurs then cease.
10% solution. start slowly then build up to 120mls/hr. watch
serum Mg++. Keep infusion pressure < 11cms H2O
urease inhibitors:- acetohydroxyamic acid, hydroxyurea. new
drugs;role uncertain.
URATE STONES.
5 - 10% of stones. No uricase in humans

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

At pH 5.75 = 50% solubilised, 50% ppt. ie: pKa = 5.75. As urine pH


Incidence

, solubility

with inflammatory bowel disease, ileostomy acidic urine.

4 categories of uric acid stone;


a) idiopathic. normal serum + urinary levels.
b) hyperuricaemia. 25% patients with gout form stones
25% "
" uric acid stones have gout
c)chronic dehydration; diarrhoea, ileostomies.
d)hyperuricosuria without hyperuricaemia.
M > 800mg/24hrs
F > 750mg/24hrs.
Thiazides & salicylates can cause hyperuricosuria.
Dx. X-rays. radiolucent. U/S=bright echoes. CT=high houndsfield No.
Rx. a) dilute urine.b) alkalinise pH 6.5 -7.0. home check with nitrazine paper.
dissolution
orally approx 3 -4 mos. direct irrigation much quicker. c)low purine
diet if hyperuricosuric
d)allopurinol if hyperuricaemic.
STONES IN PREGNANCY;
Infrequent; 1: 200 - 4000 deliveries.
renal colic 12% - 1st trimester, 44% 2nd, 44% 3rd.
physiologic changes of pregnancy contribute to stone formation by
stasis. Ca++
excretion pregnancy. Citrate excretion in pregnancy.
'Hydronephrosis'of pregnancy d.n occur before the tenth week.
Avoid X-rays. U/S preferable. Limited IVU if necessary.
Rx. avoid drugs. retrograde stent or PCN. leave stent in until
delivered.

--------------------------------------------------------------------

SURGICAL TREATMENT OF STONE DISEASE;


a) conservative
obstuction may be partial or complete. Pain in complete obstruction may resolve with
forniceal rupture. Completely obstructed renal units should be treated unless the stone shows early
signs of passage.
Stones causing partial obstruction may be treated expectantly for longer but
caution
should be taken to not leave obstruction for longer than 3/52 ( based on
experimental canine
obstruction).

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009
GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

Small ureteric calculi are mostly Rxed expectantly. 85% calculi < 5mm will
spontaneously.

pass

Most surgical intervention via ESWL. PCNL most common for large stones and
(+/- ESWL). Open stone surgery still practised but becoming a 'lost art'.

staghorns

Interventional treatment;
1) Ureteric stenting. Obstruction can be overcome by manipulating proximal ureteric
stones into the renal pelvis and maintaining
ureteric patency by stenting with a
small calibre ureteric stent. If
the stone can not be manipulated then stents can
often be manipulated past the obstruction (esp with glidewires etc.)
2) Nephrostomy. Patients with urosepsis due to obstruction are usually best treated
by
urgent decompression via nephrostomy.
The stone can then be treated once sepsis has resolved . Dilatation of the nephrostomy tract
may allow percutaneous stone removal in selected cases.
3) ESWL (in-situ & following stenting.)
Russia 1950's. Dornier; shock waves over aircraft wings
developed HM1 (prototype). widespread use of HM3.

Evaluate;
stone size, number and location. Cystine & Ca oxalate monohydrate are hard and
be recalcitrant to fragmentation. spiculated appearance correlates with fragmentation.

may

Lower third ureteric stones may be poorly visualised and require techniques such as
'signposting' with a ureteric catheter or intermittent ureteric contrast injection.
Absolute contraindications; pregnancy, bleeding disorders, uncorrected distal obstruction.
childbearing age,
Relative contraindications;pacemakers. Lower ureteral stones in females of
aneurysms, stones over bones.
Treat distal calculi first. Treat prone if anterior kidney, medial portion of horseshoe,
transplants.
Small or poorly calcified stones may need 'signpost' or give I.V contrast.
Shock waves coupled to EKG in high energy machines so as not to shock on r wave.
More sensible to couple to respiration. Low energy machines not coupled.

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009
GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

Safe shock wave dosage is unknown.


Complications rare; 0.66% perirenal haematomas
of J stents.
pancreatitis rarely with left sided stones.
nerve palsies - poor positioning
steinstrasse - if symptomatic then decompress,
'bang' the steinstrasse, consider
ureteroscopic removal of leading calculi.
hypertension - no study convincingly shows
increased incidence over age matched controls.
Stone free rates. calculi > 1.5cm stone free 75% @ 3/12.
< 1.5cm stone free 90% @ 3/12.
as monotherapy for staghorns < 50%
with PCNL < 80%
85% stone free rate in the ureter with
in-situ ESWL
Stents; manipulate stone into kidney and relieve obstruction. also create fluid
around stone(compression chamber). Prevent steinstrasse.
Stents seem simplistic but often cause severe irritative vesical

symptoms to

interface

patient.

PERCUTANEOUS RENAL STONE SURGERY;


Common procedure for stones > 1.5cm. principle of dilating avascular tract through
calyx to accomodate 26 - 30 fr sheath through which a
variety of telescopes , grabbers
and fragmentation devices can be passed.
Most staghorns treated in this way with eswl to 'mop up' fragments.
Calyceal diverticula ideally treated in this way.
Complications of PCNL;
1) wrong calyx
2) perforated kidney
3) damage to other viscera
4) non- fragmentation
5) haemorrhage
6) pelvicutaneous fistula
delayed haemorrhage may be due to traumatic a-v fistula

URETEROSCOPY.
Useful technique for ureteral stones. Endoscopes 6fr to 11.5fr. The larger calibre
scopes require dilatation of ureteral meatus. The miniscopes are less
traumatic but less able to
accommodate fragmentation devices. Fragmentation
devices include EHL, ultrasound, lithoclast,

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

laser energy. Ureteroscopy is ideal for juxtavesical stones. Laser energy through a miniscope is the
ideal fragmentation energy. Pulsed dye lasers and the holmium laser are
the most frequently used systems. Optical hazards to the operator can
be reduced
by
using video endoscopy.
Most ureters can be easily traversed with small calibre endoscopes
(miniscopes).
Difficult to traverse ureters can be often be negotiated with the aid of
external pressure over the
abdomen and renal angle to straighten the ureter. If
lasertripsy is to be attempted on upper
ureteric calculi then the patient should be
paralysed to allow the anaesthetist to cease the
patients repiratory excursions for
the pulses.
The better miniscopes have two channels to allow simultaneous irrigation and
instrumentation.
Hint; when entering orifice rotate scope so that orifice is held open.
If any trauma to ureter leave a stent in place.

drainage or

Complications of ureteroscopy;
1) haematuria
2) ureteral injury (4% perforation rate)
3) reflux
4)UTI
5) Stricture(0.5 - 3 %)
6) Ureteral avulsion
7) Instrument breakage.

RENAL/URETERIC STONE SURGERY.


Objectives.

1) remove all calculi


2) repair correctable deformity
3) eradication of UTI
4)preserve functioning tissue
5)prevent recurrent stones

remove stone if; intractable UTI, progressive renal damage,


Pre-opnature & configuration of calculus
degree of function of both renal units.
identify cause of stone formation
preliminary metabolic evaluation.
if HyperPTH, remove adenoma before stone.
MSU
consider angiography in anatrophics and horseshoes.
Reasonable grasp of intrarenal antomy is essential;
calyces 8 - 12 (av 8)
polar calyces often compound

obstn,pain,haematuria.

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009
GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

Renal Arterial Anatomy


70% renal units have single renal aretery.
50% post division is 1st branch
50% upper or lower segmental br is 1st
Renal a. gives ant & post divisions, also gives ureteric and adrenal branch.
Ant division gives

a) apical a. (of Graves).


b) superior segmental br.
c) anterior segmental br.
d) inferior segmental br.
= 'Lobar' branches.

Lobar give the interlobar (paracalyceal a's.). 8 - 12 interlobar ascend in Bertins


columns.
These give rise to the arcuate = arch over the base of the pyramid. Arcuate
give rise to
interlobular which give afferent areterioles to glomeruli.
Angiography shows vessels to level of arcuates. some
branches from arcuate go
straight through renal substance to anastamose with capsular vessels.
Superior segmental a. nearly always has extra-hilar origin; in 50% of cases
anterior surface only; 50% supplies all of upper pole.
Br. to inferior segment is mostly extra-hilar.

supplies the

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
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PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

Renal veins form free anastamosis. Posterior approach allows I,d of renal vessels.
Approaches;
1)loin approach -based on 12th rib tip incision.
2)lumbotomy.

3)Anterior approach - useful in pts with spinal deformity and horseshoes.


Renal hypothermia.
lowering core T0 to 150 - 200 provides maximal protection.
allows operating time of 2 hrs.
Intraoperative stone localisation;
nephroscopy and radiography.
Always remember; locate ureter + control it, ensure X- ray
availability in theatre, irrigate collecting system vigorously, drain the
kidney poorly visualised pre-op ensure RGPG to visualise ureter.

pelvis. If

post
Pyelonephrolithotomy; dissect kidney free. loop the artery. Bring entire kidney +
surface into op field. Incise posterior renal pelvis. Reconstitute
perinephric fat at
end of procedure.

HOLLYWOOD
UROLOGY
Monash Avenue, Nedlands
WA 6009
GLENGARRY
UROLOGY CENTRE
Arnisdale Road, Duncraig
WA 6023

PERTH UROLOGY
Suite 108, Specialist
Medical Centre
Joondalup Health Campus
PO BOX 242,
Joondalup WA 6919
Tel: 08 9400 9940
Fax: 08 9400 9939

Robert B. Thomas F.R.A.C.S. (UROL)


Email: info@perthurology.com

Anatrophic Nephrolithotomy; for branched calculi with infundibular stenosis,


prior stone surgery.
Prior to clamping renal artery give mannitol 25gms I.V.
osmolarity of the Glom Filtrate + Ice crystal formation.
This
Incise capsule sharply and then use handle of scalpel to blunt dissect to calyces. remove
stones and inspect for fragments. Insert nephrostomy and reconstruct pelvis
into one large calyx.
Coagulum; probably never see used. based on cryoppt (with high risk of transmissible
agents.)
Radial nephrotomies into thinned parenchyma can be useful. If necessary the
tolerate 15" of warm ischaemia.

kidney can

Partial nephrectomy occasionally still useful for severely diseased renal poles.
Nephrectomy = final resort in non-function. may sometimes be best first up option in
unwell patients with marginal function in that unit.

URETERAL STONE SURGERY.


still has useful role. Always radiograph on way to theatre.
always rule out distal obstruction. If IVU d.n show distal ureter
consider rgpg. Always gain prox and distal control of ureter.
lower ureter;- midline, pfannenstiel, gibson. often helpful to arch
lower back.
middle and upper ureter;- 12th rib tip incision. Occ lumbotomy.
Incision directly onto stone. flush ureter distally and proximally through No. 8 infant
feeding tube. Prob best to stent and drain all ureterolithotomies, but no firm
evidence.