1. Urologic Issues for the Nephrologist
신장내과
위 지 완

2. Contents Management of Stone Disease
Management of Urinary Tract Obstruction
Investigation of Hematuria

3. Management of Stone Disease

4. Changing use of techniques for stone removal
The management of urinary tract stones has been irrevocably changed by the introduction of extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), and ureteroscopy

5. Advances in Imaging for Urinary Tract Stones
TOC
Non-contrast CT or
Ultrasonography
Sensitivity
CT 88% > USG 54-57%

6. Treatment of Urinary Tract Stones
Spontaneous stone passage can be expected in up to 80% of patients with a stone size smaller than 4mm
Stones >7mm : spontaneous stone passage is very low
The location is also important
Distal ureteral stone: ~70% pass spontaneously
Midureteral stone: 45%
Proximal ureteral stone: 25%

7. Treatment of Urinary Tract Stones
Intervention indication
Persistent pain (>72 hours) despite adequate analgesia
Persistent obstruction with risk of impaired renal function
Bilateral obstruction
Associated urinary tract sepsis
Medical expulsive therapy
<10mm
Alpha blocker (Tamsulosin, terazosin, doxzosin)
Nifedipine 30mg once daily
Relaxes the distal ureter -> stone passage

8. Acute Surgical Intervention
Well enough for general anesthesia
Ureteroscopic stone destruction
Alternatively, a double-J stent can be inserted, which will relieve obstruction until definitive treatment is performed
Uncontrolled urinary tract infection
Percutaneous nephrostomy (PCN) - preferred option
It can be performed with local anesthesia and is less likely than endoscopic surgery to cause septicemia
Contrast material is injected through a percutaneous nephrostomy tube placed in the lower pole calyx (arrow).The contrast material outlines a single large calculus (arrowheads) producing complete obstruction at the pelviureteral junction.

9. Management of Symptomatic Nephrolithiasis

10. Treatment options Radioopaque(Ca), ≤2cm Preference Procedure 1 ESWL 2
PNL
Radioopaque(Ca), >2cm
Preference
Procedure 1
PNL 2
ESWL
Radiolucent(Uric acid)
Preference
Procedure 1
Oral chemolysis 2
ESWL+
oral chemolysis
Staghorn stone
Preference
Procedure 1
PNL 2
ESWL

11. Extracorporeal Shock Wave Lithotripsy
First-line treatment for more than 75% of stone patients
Acoustic shock wave energy is delivered to a stone under fluoroscopic or ultrasound guidance
Treatment sessions - 30 minutes, 1500~2500 shock waves
Stones up to 20mm in size, stone-free rates 60-98%
Cystine and calcium oxalate monohydrate stones - resistant

12. Extracorporeal Shock Wave Lithotripsy
Contraindication
Aortic or renal artery aneurysm
Uncontrolled urinary tract infection
Coagulation disorders
Pregnant women
Complication
Hemorrhage
Hematoma
Infection
Injury to adjacent organs

13. Percutaneous Nephrolithotomy

14. Percutaneous Nephrolithotomy
Procedure
Retrograde ureteral catheter placed
Renal collecting system accessed(dorsal calyx of the lower pole) under fluoroscopic guidance
Dilatation of the tract with a nephrostomy balloon dilatator
Calculi extracted with grasping forceps using nephroscope, fragmented using an ultrasonic, pneumatic lithotripsy probe
Complication
Hemorrhage
Sepsis
Fluid overload (similar to transurethral resection syndrome)
Injury to spleen, pleura, or colon

15. Ureteroscopy
Ureteroscopy continues to be the treatment of choice for the majority of middle and distal ureteral stones
Semirigid or flexible (allow access to the renal pelvis and calyces)
Stone fragmentation by laser, ultrasound, pneumatic devices
Laser use - allowing intrarenal stone fragmentation, low tissue penetration, minimal stone displacement
Complications of ureteroscopy (particularly graspers and baskets)
Ureteral avulsion, perforation, extravasation, mucosal damage, hematuria, infection, stricture
Advances in laser technology now enable stones to be reduced to dust-like particles, reducing the need for graspers and baskets and hence reducing complications.

16. Stones in Transplanted Kidneys
The management of stone disease in a transplanted kidney is challenging because of the solitary kidney, the anatomic location within the pelvis, and the difficulty with retrograde access to the ureter and kidney
Early active intervention is indicated
Prophylactic stenting, ureteroscopy, and PCNL are preferred to ESWL because stone targeting may not be possible

17. Management of Urinary Tract Obstruction

18. Causes and Presentation
Malignant disease can be a result of direct tumor invasion or external compression by metastatic lymph node involvement or, rarely, true metastasis to the ureter
70% - genitourinary (cervical, bladder, prostate) in origin
Remainder – breast, gastrointestinal carcinomas and lymphoma
Presentation
Vary significantly
Remain unrecognized until the patient develops anuria and uremia 

19. Acute Management of Urinary Tract Obstruction
Relief of obstruction is crucial to reverse renal impairment and to preserve remaining renal function
Bladder outflow obstruction: urethral or suprapubic catheter
Upper tract obstruction: double-J ureteral stent
In whom the procedure fails: PCN
Tumor infiltration can distort trigonal anatomy, making identification of ureteral orifices for double-J stent insertion impossible
Stents fail to relieve obstruction in 40-50% of cases of external ureteral compression

20. Acute Management of Urinary Tract Obstruction
Patient with sepsis, not be fit for general anesthesia
PCN → antegrade ureteral stenting
Bilateral ureteral obstruction
Not always necessary to insert bilateral PCN tubes
Significant palliation and return to nearly normal renal function can be accomplished by drainage of a single kidney, preferably the unit with the better preserved parenchyma as determined by CT scan or ultrasound
Complications of ureteral stent or PCN
Migration, obstruction(stent>PCN), infection(PCN>stent), fragmentation, erosion through the urinary tract, lower urinary tract symptoms
As many as 70% of patients with stents report lower urinary tract symptoms (LUITS), mainly urgency, frequency, and nocturia as well as pain along the urinary tract.
Extra-anatomic stents are an alternative for patients in whom conventional stent insertion has failed or for whom permanent nephrostomy drainage is unacceptable. An extra-anatomic stent is placed by an initial percutaneous puncture and insertion of the upper end of a long (50-cm) double-J stent into the kidney. A subcutaneous tunnel is then created to bring the stent to the level of the iliac crest. Another tunnel is fashioned to bring the lower end of the stent out suprapubically, followed, finally, by suprapubic puncture of a full bladder and insertion of the lower end (Fig. 61-6).11 Extra-anatomic stents are usually changed at 6-month intervals, and preliminary experience confirms their value in maintaining ureteral patency and avoiding PCN

21. Investigation of Hematuria

22. Casuses of hematuria

23. Outcome of Evaluation in a Hematuria
A prospective analysis of 1,930 patients with hematuria to evaluate current diagnostic practice.J Urol. 163:  2000

24. Evaluation of Macroscopic Hematuria
All adults with a single episode of macrohematuria require full urologic evaluation, including renal imaging and cystoscopy
The only exception
< 40 years
Hx of characteristic of glomerular hematuria (dark brown hematuria lasting 24 to 48 hours coincides with intercurrent mucosal infection, usually of the upper respiratory tract)
Should be referred first for nephrologist
Typically seen in IgAN

25. Evaluation of Microhematuria
Patients with urinary tract infection should be treated appropriately, and urinalysis should be repeated 6 weeks after treatment.
The use of adjuncts to AMH workup such as urine cytology and other urine biomarkers is no longer advocated.