Title 28 Urology LMV 5.1.pdf ✅

1 | P a g e [ U r o l o g y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Copyrights @ Plab1Keys.com Urology Version 5.1 Corrected, Updated, Lighter PLAB 1 Keys is for PLAB-1 and UKMLA-AKT (Based on the New MLA Content-Map) With the Most Recent Recalls and the UK Guidelines ATTENTION: This file will be updated online on our website frequently! (example: Version 2.1 is more recent than Version 2, and so on) Key 1 Managing Renal Stones ◙ Sudden colicky Pain in loin/flank radiates to groin/ abdomen + nausea, vomiting, hematuria (blood in urine), ± rigours Think → Ureteric “renal” Stones. ◙ The Investigation of Choice for Ureteric Stones: → Non-contrast “Spiral” CT scan of KUB “Kidney, ureters, bladder”. (CT KUB, not U/S KUB)! Plab1keys.com Strict Copyrights! No Sharing or Copying Allowed by any means Compensations and Penalties Worldwide System is Active
2 | P a g e [ U r o l o g y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Copyrights @ Plab1Keys.com If pregnant woman → Ultrasound of KUB. Management → Generally depends on the Stone Size Rule: ◙ If stone size < 0.5 cm (< 5 mm) → ↑ fluid intake to get rid of it in urine. ◙ If stone size 0.5 cm – 2 cm (5-20 mm) → two options: √ ESWL (Extracorporeal Shock wave Lithotripsy) “preferred”, or: √ [Ureteroscopy] with dormia basket. “Ureteroscopy is preferred over ESWL if the patient has hydronephrosis. This is because in ureteroscopy, we can insert JJ stent to relieve ureteric obstruction”. ◙ If stone size > 2 cm (> 20 mm) → Percutaneous Nephrolithotomy. HOWEVER! ◙ If the patient has only one functioning kidney (e.g., Hx of the removal of one kidney) and has a stone (OF ANY SIZE) with dilatation of the pelvicalyceal system (PCS) ± Anuria, Fever [Obstructive Uropathy] → The INITIAL thing to do is to decompress the PCS to save the remaining kidney. This is done by → Percutaneous Nephrostomy If Percutaneous nephrostomy is not among the options, pick “ureteric stent”. √
3 | P a g e [ U r o l o g y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Copyrights @ Plab1Keys.com We need to drain the urine first to relieve the obstruction and save the AKI. ◙ Similarly, even if the patient has 2 kidneys, if he develops AKI (impaired urea and creatinine), fever and Hydronephrosis (these together with the presence of stones are indicators of Obstructive Uropathy), we shall go for (Percutaneous Nephrostomy) in order to temporarily and instantly decompress the renal collecting system regardless of the stone size! ◙ Important: What if both Nephrostomy AND Ureteric stenting (JJ stent) are in the options? √ If BMI is normal or not given in the stem → Nephrostomy. √ If BMI is high eg, 40 kg/m2 (the patient is Obese) → Ureteric stenting. This is because percutaneous nephrostomy in Obese patient would be difficult. It is done under interventional radiology (U/S). Due to fat, the clarity of U/S would be reduced. Also, inserting a catheter through big fatty layers is difficult. Inserting JJ stent (ureteric stenting) would allow the collecting urine to pass down and the peristalsis of ureters to run again and would relieve the obstruction. This may lead to the stone to be extracted in urine or in many cases it would be followed by ureteroscopy or ESWL “definitive management”. Note, Percutaneous nephrostomy is different form Percutaneous nephrolithotomy.
4 | P a g e [ U r o l o g y ] © Copyright www.plab1keys.com (Constantly updated for online subscribers) Copyrights @ Plab1Keys.com • Percutaneous Nephrostomy → stoma “catheter” to the Pelvicalyceal system of the kidney for decompression (Draining the obstructed fluid in kidney). • Percutaneous Nephrolithotomy → removal of urinary stone percutaneously via a scope (if size > 2 cm). Example (1): 46 YO ♂ with Hx of left nephrectomy 10 days ago presents with fever, inability to pass urine for the last 20 hours. Ultrasound reveals an 8 mm stone in the left lower ureter with dilatation of the pelvicalyceal system. What is the best INITIAL step in management? • The best initial step → Percutaneous Nephrostomy. The (Stone Size Rule) does not apply here. This patient has obstructive uropathy with impending renal failure. We need to, initially, save his remaining kidney by decompressing the fluid retention in the PCS. This can be done by → Percutaneous Nephrostomy. Afterwards, we can manage the stone based on the stone size role; (ESWL) in this case. In summary: ◙ Loin pain + Stone ± Hydronephrosis → Manage according to the stone size. ◙ Loin pain + Stone + Hydronephrosis [+] AKI [+] Fever → Percutaneous Nephrostomy, initially.