The evaluation and management of urolithiasis in the ED: A review of the literature

Background

Urolithiasis is a common condition in the U.S. Patients frequently present to the emergency department (ED) for care, including analgesia and treatments to facilitate stone passage.

Detection of distal ureteral stones in pregnancy using transvaginal ultrasound

AimsTo determine the performance of transvaginal ultrasound for the visualization of distal ureteral stones in pregnant patients with renal colic and to evaluate the diagnostic value of secondary findings suggestive of obstructing ureteral stone disease.MethodsWe retrospectively identified 129 pregnant patients with a total of 142 encounters with both abdominal and transvaginal ultrasound. Ultrasound images for each patient were reviewed recording the presence of stone with location, hydronephrosis, resistive indices (RI), and status of the ureteral jets. Patients were subcategorized into two groups based on the visualization of distal ureteral stone.ResultsThe transvaginal technique identified 94% (N = 16/17) of sonographically detected stones in the distal ureter/urethra, while the transabdominal technique identified 29% (N = 5/17). The combined imaging for initial assessment of renal colic in pregnancy demonstrated a sensitivity of 89%, specificity 100%, and negative predictive value (NPV) of 98%. The frequency of hydronephrosis was statistically greater in the visualized stone group (94% vs 51%). Mean RI was identical in both groups however the delta RI was significantly elevated in those patients with distal ureteral stones with a mean delta RI value of 0.05. The rate of absence of ureteral jets was not statistically significant.ConclusionThe present data would suggest a utility of transvaginal ultrasound for the evaluation of the pregnant patient with 94% of distal stones being detected transvaginal versus 29% transabdominally. Additionally, there was significantly increased hydronephrosis and elevated RIs in patients with distal ureteral stones.     

Medical and medical/urologic approaches in acute and chronic urologic stone disease

Urinary stone disease is a condition with far-reaching implications. Patients with their initial instance of acute renal colic enter the health care system through 2 routes. Severe cases are generally seen in the emergency room, whereas more tolerable cases may be seen by primary care physicians. Patients with urinary stone disease are then managed in the long-term by a urologist. Timely and appropriate treatment of patients with urinary stone disease is essential to prevent the development of sepsis and progressive renal insufficiency. This article reviews the epidemiology, pathogenesis, presentation, and short- and long-term management of acute and chronic urinary stone disease.     

Simultaneous vs staged treatment of urolithiasis in patients undergoing radical prostatectomy

AIM: To assess the outcomes of men treated for urolithiasis at the time of radical prostatectomy.METHODS: From 1991 to 2010, 22 patients were retrospectively identified who were treated simultaneously (n = 10) at radical prostatectomy, or (n = 12) within 120 d prior to prostatectomy, for urolithiasis. Clinical characteristics were reviewed including: type of prostatectomy and stone surgery, location and amount of stone burden, perioperative change in hemoglobin and creatinine, stent frequency, total hospital d, stone-free rates, additional stone procedures and complications. Long-term functional outcomes including stress urinary incontinence and bladder neck contracture were reported. Differences between cohorts (simultaneous vs staged treatment) were assessed.RESULTS: Among men undergoing radical prostatectomy, primary stone procedures included 12 ureteroscopy, 6 shock wave lithotripsy, 2 open nephrolithotomy and 2 percutaneous nephrolithotomy. In staged shock wave lithotripsy there were 4 complications and 3 additional procedures vs 1 (P = 0.5) and 0 (P = 0.2) in the simultaneous cohort. Meanwhile in staged ureteroscopy there were 5 complications and 1 additional procedure vs 1 (P = 0.2) and 1 (P = 0.9) in the simultaneous cohort. Additional procedures for residual stones was greater among patients with asymptomatic upper tract calculi 3 (60%) relative to patients with symptomatic stones 2 (13%; P = 0.02). Likewise, patients with proximal or multiple calculi had a greater total hospital days 5.5 vs 4.1 (P = 0.04), additional procedures 6 vs 0 (P = 0.04) and lower stone-free rates 39% vs 89% (P = 0.02) relative to men with distal stones. Finally, there was no difference in the incidence of bladder neck contracture (P = 0.4) or stress urinary incontinence (P = 0.7) between cohorts.CONCLUSION: Ureteroscopic treatment of symptomatic distal urolithiasis at radical prostatectomy appears to be safe and efficacious with a low rate of adverse postoperative outcomes.     

A role of the endothelial nitric oxide system in acute renal colic caused by ureteral stone

Background and aims

Endothelial nitric oxide synthase gene polymorphisms play a role in some pathophysiological processes. In this study, the possible effects of endothelial nitric oxide synthase gene polymorphisms on ureteral stone disease in patients who were admitted to the emergency department with severe pain due to renal colic are examined.

Cumulative CT exposures in emergency department patients evaluated for suspected renal colic

Computed tomography (CT) is the diagnostic standard in Emergency Department evaluation of suspected renal colic but delivers substantial radiation. We determined the frequency of CT scan in suspected renal colic, diagnosis and outcome, and cumulative CT scans per patient. A retrospective chart review with waiver of informed consent was conducted. A total of 356 patient encounters were reviewed from January to October 2003. Mean age was 39 years. Seventy-four percent included a CT scan, with 38% normal, 58% showing urolithiasis, and 1% showing emergent etiologies. Six percent of patients undergoing CT were admitted for urolithiasis, and 6% had a urologic procedure within 7 days. Sixteen percent of patients did not have a CT scan, and 79% underwent two or more CT scans. Emergency Department patients presenting with symptoms suggesting renal colic are likely to undergo CT on multiple occasions. Radiation exposures from repeated CT scans are substantial, and a clinical decision rule for this scenario is needed.     

输尿管中下段结石并急性肾绞痛急诊输尿管镜钬激光碎石治疗

目的探讨急诊输尿管镜钬激光治疗输尿管中下段结石并肾绞痛的效果。方法对25例输尿管中下段结石致急性肾绞痛患者行急诊输尿管镜钬激光碎石治疗。结果 25例手术均获成功,肾绞痛缓解率100%,碎石成功率96%,4周后结石排净率92%。结论输尿管中下段结石导致的急性肾绞痛患者行急诊输尿管镜钬激光碎石术安全有效,排石率高。     

彩超对肾结石患者肾动脉血流改变的研究

目的 :探讨肾结石患者肾动脉血流的改变。方法 :对 110例肾结石患者和 87例正常人肾动脉的对比研究。结果 :1、肾结石组肾动脉峰值流速高于对照组 ,二者比较有显著性差异 (P<0 .0 1)。 RI有极其显著性差异(P<0 .0 1) ;2、肾结石患者肾动脉峰值流速随肾盂积水程度的增加而增高 (P<0 .0 1) ;3、肾结石患者肾动脉峰值流速与结石大小无明显关系 (P>0 .0 5 ) ;4、肾盂结石、肾盏结石患者组肾动脉峰值流速高于肾内结石组 (P<0 .0 1) ;5、肾盂结石患者组肾动脉峰值流速高于肾盏结石组 (P<0 .0 1)。结论 :1、肾结石患者肾动脉出现痉挛现象 ;2、肾结石患者肾动脉痉挛程度与肾积水程度呈正比 ;3、肾结石患者肾动脉痉挛与结石部位有关     

食用含三聚氰胺奶粉婴幼儿泌尿系统结石的危险因素分析

目的探讨食用含三聚氰胺奶粉的婴幼儿发生泌尿系结石的危险因素。方法收集2008年9月14日～2009年1月6日在兰州大学第二医院进行免费筛查的食用含三聚氰胺奶粉的婴幼儿病历,根据发生结石的病例数按1：1比例从无泌尿系结石的婴幼儿中随机抽取对照组,采用logistic回归模型对泌尿系结石的危险因素进行单冈素和多因素分析。结果结石组647例,对照组647例,男678例,女616例,平均年龄19．27月。食用高三聚氰胺含量的二三鹿奶粉婴幼儿发生泌尿系结石的OR为6．09（P〈0．01）,其中婴儿性别为男、人工喂养的OR值分别为1．39（P〈0．01）和1．61（P〈0．01）。随着年龄增长发生结石的风险逐渐下降,〈6月、6月-、12月～婴幼儿发生结石的OR值分别是5．23（P〈0．01）、2．73（P〈0．01）、1．60（P〈0．01）。随着食用含三聚氰胺奶粉时间的延长,发生结石的风险逐渐增加。食用含i聚氰胺奶粉3个月-、6个月～、12个月～婴幼儿发生结石的OR值分别是2．10（P〈0．01）、2．81（P〈0．01）、4．75（P〈0．01）。结论食用高三聚氰胺含量奶粉（三鹿奶粉）、人工喂养和男性是婴幼儿发生泌尿系结石的危险因素,食用含三聚氰胺奶粉时间越长、年龄越小,发生泌尿系结石的风险越高。     

移植肾输尿管结石的超声诊断

目的探讨肾移植后移植肾输尿管结石的超声诊断。方法对在1068例肾移植患者中应用彩超检出的16例移植肾输尿管结石病例进行回顾性分析。结果来自供体肾结石9例,术后形成结石7例;其中移植肾结石13例,输尿管结石1例,移植肾并输尿管结石2例;单发结石10例,多发结石6例;合并尿路梗阻8例,镜下血尿5例。结论移植肾输尿管结石无典型症状,彩超是诊断移植肾输尿管结石的可靠方法,对结石的定位及定性具有重要的价值。     

甘肃省食用添加三聚氰胺奶粉的婴幼儿结石发病情况调查

目的调查甘肃地区0～3岁7856例食用添加三聚氰胺奶粉婴幼儿泌尿系统结石的发病情况及特点。方法对2008年9月14日至2008年11月15日甘肃省兰州大学第二医院门诊部进行筛查的0～3岁的7856例婴幼儿进行问卷调查和泌尿系统B超检查,采用Excel录入资料,用SPSS13.0软件对数据进行卡方检验及描述性分析。结果接受调查的7856例婴幼儿中男性4090例（52.06%）、女性3766例（47.94%）,平均年龄18.30±9.68月,其中704例患有泌尿系统结石,患病率为8.96%,99.14%的结石部位在肾脏。704例结石患儿中男性434例（61.65%）、女性270例（38.35%）。0～6月的婴幼儿58例,患病率为3.16%;6～12月的婴幼儿218例,患病率为11.01%;12～24月的婴幼儿275例,患病率为12.55%;24～36月的婴幼儿153例,患病率为8.27%。结果显示,不同性别和不同年龄段的婴幼儿其泌尿系统结石患病率的差异有统计学意义（P〈0.05）。结论甘肃省筛查的0～3岁食用添加三聚氰胺奶粉婴幼儿泌尿系统结石患病率较高,发病年龄主要在6～24月之间,结石好发部位为肾脏,具有解剖结构特异性。     

成都地区食用含三聚氰胺奶粉儿童泌尿系统结石发病情况调查

目的调查成都地区食用含三聚氰胺超标奶粉儿童泌尿系统结石的发病情况。方法对2008年9月17日～12月9日前来四川省人民医院进行“问题奶粉”筛查的5795例儿童进行泌尿系统B超检查，用SPSS13．0软件包对数据进行处理。结果调查期间筛查的5795例儿童中，患有泌尿系统结石者24例，发生率为0．41％。其中男12例，女12例；平均发病年龄2．35-1．68岁。调查结果显示，成都地区儿童泌尿系统结石的发病与性别无关（P〉0．05），婴幼儿（≤3岁）组泌尿系统结石发生率高于学龄前和学龄期年龄（〉3岁）组（P〈0．05）。结论成都及周边地区食用“问题奶粉”的0—3岁婴幼儿泌尿系统结石发生率较高，远期后遗症尚待随访。     

甘肃省三聚氰胺奶粉所致婴幼儿泌尿系结石402例临床分析

目的对甘肃省三聚氰胺奶粉所致婴幼儿泌尿系结石患病情况进行调查,为制定更为有效的诊断和治疗方案提供临床依据。方法对兰州大学第二医院等16个医疗机构收治的402例三聚氰胺奶粉所致婴幼儿泌尿系结石住院患儿的临床基本资料,血、尿生化检测,泌尿系B超、治疗方案及转归进行回顾性分析与调查。结果402例患儿均有三聚氰胺奶粉喂养史。其中6～12月龄婴幼儿泌尿系结石发生率最高,占50％,9例患儿自行排m结石,最大结石径4mm×5mm×6mm,最小结石径0．5mm×0．5mm×1mm,平均结石径1mm×2mm×2mm。血肌酐异常30例、血尿素氮异常27例、尿隐血阳性167例、尿酸异常2例。内科治疗385例,外科治疗14例,发生梗阻性肾功能衰竭6例。结论月龄在6个月到12个月婴幼儿食用三聚氰胺奶粉后发生泌尿系结石的风险性最大。手术治疗对结石引起的梗阻性肾功能衰竭行有效。     

输尿管镜下气压弹道碎石治疗输尿管结石

目的 探讨输尿管镜下气压弹道碎石治疗输尿管结石的临床疗效.方法 自2006年7月至2006年11月,采用输尿管镜下气压弹道碎石术治疗输尿管结石52例.结果 一次性粉碎率为84.6%,无明显并发症发生.结论 输尿管镜下气压弹道碎石术安全,损伤小,效果确切.     

Structure and function of the emergency department: matching emergency department choices to the emergency department mission

Emergency caregivers experience considerable new challenges to the provision of competent, compassionate care. The good news is there are ample new approaches and new technologies to meet those new challenges.ED leaders who understand the ED mission and the resources available today and who engage vigorously in the change process will turn that mission into immensely beneficial action.