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RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
KARNATAKA, BANGALORE.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1
Name of the candidate and
DR.SIVASAI KRISHNAPRASAD K
address
P.G.IN GENERAL SURGERY,
DEPARTMENT OF GENERAL SURGERY,
VIMS, BELLARY.
2
Name of the Institution
VIJAYANAGARA INSTITUTE OF
MEDICAL SCIENCES, BELLARY.
3
Course of the study and subject
MS IN GENERAL SURGERY
4
Date of admission to the course
10.05.2010
5
Title of the topic
RENAL CALCULI –PREDISPOSING
FACTORS, MODES OF PRESENTATION
AND MANAGEMENT AT VIMS BELLARY
6
BRIEF RESUME OF INTENDED WORK
6.1. Need for study
Urinary stone disease has perplexed the physicians for many centuries. The disorder
occurs in two forms; endemic bladder stone which occurs in boys in the developing
agricultural countries of the world and upper urinary tract stone disease which is
becoming increasingly more prevalent particularly in men among the more affluent
nations.
Although not all calculi can be cured, patients who develop one of the major
types of urinary calculi now have at least 50% chances of cure and control with
medical therapy alone. Surgery continues to be as one aspect of treatment of urinary
calculi, but it is now only one step in the total therapeutic plan for patients with
urinary lithiasis.
As the incidence of patients suffering from urolithiasis are increasing in the
department of surgery Vijayanagar Institute of Medical Sciences Bellary, a clinical
study of nephrolithiasis and its surgical management is desirable and worthwhile.
6.2 Review of Literature.
1. MEMON J.M., M. ATHAR A., AKHUND A.A. et al states that urolithiasis is
increasing problem with high frequency of bladder stones and male predominance in
our part of Sindh province. Open surgery is still needed to treat the patients where
modern and minimally invasive therapeutic modalities are out of reach and nonavailability in public sector. Establishment of modern stone clinics in rural setup is
the need of today’s medical practice.
2. Hall PM . Nephrolithiasis: treatment, causes, and prevention. Cleve Clin J Med
2009; 76:583–591. Opines that Factors that promote stone formation include low
daily urine volumes; saturation of the urine with calcium, oxalate, calcium phosphate,
uric acid, or cystine; acidic urine; and bacterial infection. The author identifies the
mechanisms of stone formation and outlines management aimed at preventing
recurrences.
During an acute stone event, medical management focuses on pain control.
Hydration and certain drugs may help the stone to pass.
Most stones are composed of calcium oxalate or calcium phosphate. Less
common are uric acid, magnesium ammonium phosphate, and cystine stones.
To prevent stones from recurring, patients who have had any type of stone
should maintain an adequate fluid intake to keep the urine dilute.
Paradoxically, calcium restriction is not warranted for patients who have had
calcium stones, and may even be harmful.
Alkalinization of the urine may help prevent recurrent uric acid stones and
cystine stones.
Medical prophylaxis is effective in up to 80% of patients with recurrent
stones10.
3. Fredric L. Coe, Andrew Evan and Elaine Worcester et al states that about 5% of
American women and 12% of men will develop a kidney stone at some time in their
life, and prevalence has been rising in both sexes. Approximately 80% of stones are
composed of calcium oxalate (CaOx) and calcium phosphate (CaP); 10% of struvite
(magnesium ammonium phosphate produced during infection with bacteria that
possess the enzyme urease), 9% of uric acid (UA); and the remaining 1% are
composed of cystine or ammonium acid urate or are diagnosed as drug-related stones.
Stones ultimately arise because of an unwanted phase change of these substances
from liquid to solid state. Here they focussed on the mechanisms of pathogenesis
involved in CaOx, CaP, UA, and cystine stone formation, including recent
developments in our understanding of related changes in human kidney tissue and of
underlying genetic causes, in addition to current therapeutics.
It is difficult to accept recurrent stone formation as incidental in any patient
and allow it to continue without efforts to understand its causes and offer such
treatments as seem appropriate. Available trials offer physicians excellent treatment
strategies for prevention of calcium stones, and since UA stones are a consequence of
low urine pH, physicians can treat them confidently despite the lack of prospective
trials for additional therapeutics. Even cystine stones can be prevented, albeit with
imperfect remedies. But treatments may pose their own problems. Although
potassium citrate salts are effective, they, along with ESWL, may promote the
formation of CaP stones, the prevalence of which continues to rise with time.
Possibly this means that the use of citrates requires special attention to avoid
increasing CaP SS excessively via high urine pH. Although we treat urine SS, the
tissue processes of stone formation are complex, not as yet obviously related to
solution chemistry within specific nephron segments, and not well understood. This
is a significant area of interest that requires new research. Abnormal urine pH and
calcium excretion rate are predominant findings in SFs that play a major role in the
pathogenesis of stone formation. Their biologies are therefore also of particular
research importance. Perhaps most important in the long run will be uncovering the
links between genetic variability and urine calcium excretion and pH, for these seem
at the very center of the problem of kidney stone disease.
4. The article published in BMJ 2002; 325 : 1408 doi: 10.1136/bmj.325.7377.1408
suggests that there is uncertainty about the immediate management of patients
presenting with acute renal colic in primary care, and whether this can be overcome
by adopting a pre-established integrated pathway of care across the primarysecondary care interface
Intramuscular diclofenac 75 mg is recommended as first line of treatment when the
diagnosis is clear and there are no signs of complications
If the severe pain does not remit within an hour the patient should be admitted to
hospital
All patients, whether managed at home or in hospital, should be offered fast track
urological investigation with follow up
Opaque radiography and ultrasound are being augmented by the use of spiral
computed tomography in some centres in certain situations
5. Less-invasive interventions for upper tract urolithiasis are extracorporeal shockwave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy. Each has
advantages and disadvantages, depending on the location, size, and composition of
the stone and on the patient’s renal anatomy, body habitus, and comorbidities.
Stones that obstruct the flow of urine or that are associated with infection (ie,
struvite or “staghorn” stones) should be removed promptly.
For small stones in the distal ureter, medical therapy is an option: pain
control, hydration, and control of ureteral spasms with calcium channel blockers and
alpha-blockers help the patient pass the stone spontaneously.
Extracorporeal shock-wave lithotripsy is the mostly commonly used option,
but it is less effective for large stones and in obese patients.
The ureteroscope can now be used to extract stones as high up as the kidney.
Catheters that contain lasers and lithotripsy devices can break up large stones in situ
for removal.
Percutaneous nephrolithotomy is very effective for large stones in the kidney
and is especially indicated for struvite stones13.
It should be emphasized that with the wide array of options (SWL, URS,
PNL) available to treat stones today, routinely approaching stones with an “SWL
challenge”, without taking into account factors such as size, composition, location,
etc., does not constitute standard of care.7
6.
Brian R. Matlaga, Dean G Assimos’ study of role of open stone surgery opines
there is still a role, albeit minimal, for open surgical stone removal. These patients
typically have extremely complex calculous disease with associated anatomic and
physiologic derangements. It is important to identify these patients early on so that
less effective therapy is not chosen
6.3. OBJECTIVES OF THE STUDY
1. To study the patients with renal stones with regards to various variables like age,
sex, and occupation.
2. To study the mode of presentation of renal stone.
3. To study various predisposing factors of renal calculi.
4. To study the different modes for management of renal stones at VIMS Bellary
7. MATERIALS AND METHODS
The patients attending the department of SURGERY and UROLOGY and also
patients referred from other departments of combined hospitals of MCH VIMS,
Bellary form the subjects of our study.
In this study all patients diagnosed as renal calculi and admitted in surgical and
urology wards at VIMS, Bellary during the period of January 2011 to December
2011. A detailed history, complete physical examination routine and specific
investigations were done
INCLUSION CRITERIA
1. all patients who are diagnosed as renal stones and admitted to surgical and
urology wards VIMS, Bellary during January 2011 to December 2011.
EXCLUSION CRITERIA
1. Stones below the pelviureteric junction
7.2. a) METHOD OF COLLECTION OF DATA
A written informed consent will be taken from all patients included in the
study. A detailed history-taking, thorough clinical examination will be done
for these patients. The data collected will be entered into a specially
designed case record form.
b) Duration of study
The study will be conducted for a period of one year from
January 2011 to December 2011.
7.3.
DOES
THE
STUDY
REQUIRE
ANY
INVESTIGATIONS
OR
INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER
HUMANS OR ANIMALS?
YES
All the patients included in the study are investigated with
1. Urine examination macroscopic, microscopic, biochemical and bacteriological
examinations.
2. Routine blood investigations
(Random blood sugar, Blood Urea, Serum Creatinine, Hb %, RBC and WBC count)
3. Serum Calcium and serum phosphate
4. Radiological investigations
KUB X-ray, ultrasound abdomen, IVU.
7.4 . HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION?
YES.
Ethical Clearance has been obtained from Institutional Ethical Committee (IEC) of
VIMS, Bellary.
8
. LIST OF REFERENCES:
1. MEMON J.M., M. ATHAR A., AKHUND A.A. et al; Cleveland Clinic Journal
of Medicine 2009; 76(10):583-591
2. Hall PM . Nephrolithiasis: treatment, causes, and prevention. Cleve Clin J Med
2009; 76:583–591
3. BMJ 2002; 325 : 1408 doi: 10.1136/bmj.325.7377.1408
4. Fredric L. Coe, Andrew Evan
and Elaine Worcester et al; J Clin Invest.
2005;115(10):2598–2608.
5. Samplaski MK, Irwin BH,Desai M . Less-invasive ways to remove stones from
the kidneys and ureters. Cleve Clin J Med 2009; 76:592–598.
6. Brian R. Matlaga, Dean G Assimos. Role of open stone surgery; Braz J of
Urology. 2002; 28: 87-92.
7. Robert Marcovich. Renal pelvic stones: Choosing Shock wave lithotripsy or
percutaneous nephrolithotomy. International Braz Jour of Urology. 2003; 29:
195-207.
8. Jens J. Rassweiler, Christian Benner. Management of staghorn calculi: Critical
analysis after 250 cases. Braz J of Urol. 2000; 26: 463-478
9. Coll DM, Varanelli MJ, Smith RC : Relationship of Sponteneous passage of
ureteral calculi to stone size and location as revealed by unenhanced helical
CT. Am J Reontgenol, 2002; 178: 101-103.
10. Medical Aspects of Renal Stones; KK MalhotraJIACM 2008; 9(4): 282-6
11.Orson
W Moe, Margaret S Pearle and Khashayar Sakhaee Pharmacotherapy of
urolithiasis Kidney International , (6 October 2010) | doi:10.1038/ki.2010.389
12. A Comparative Study of Two Renal Stone Analysis Methods Samira Charafi1,
Mohamed Mbarki, Antonia Costa-Bauza, Rafael M. Prieto, Abdelkhalek Oussama1,
Felix Grases Int J Nephrol Urol, 2010; 2 (3): 469-475
13. A prospective randomized trial of open surgery versus endourological stone
removal in patients of staghorn stones with chronic renal failure; Anant Kumar,
Balbir S Verma, Sanjay Gogoi, Rakesh Kapoor, Aneesh Srivastava, Anil Mandhani
Indian Journal of Urology, Year 2001, Volume 18, Issue 1 [p. 14-19]
14. Percutaneous nephrolithotomy for 1-2 cm lower-pole renal calculi Percy Jal
Chibber Indian Journal of Urology, Year 2008, Volume 24, Issue 4 [p. 538-543]
15. Outcome of shock wave lithotripsy as monotherapy for large solitary renal stones
(>2cm in size) without stenting; Shanmugasundaram Rajaian, Santosh Kumar,
Ganesh Gopalakrishnan, Ninan K Chacko, Antony Devasia, Nitin S; Indian Journal
of Urology, Year 2010, Volume 26, Issue 3 [p. 359-363]
9
Signature of the candidate
10
Remarks of the guide
11
Name and designation of the
Dr. VASANTH SHET
11.1. Guide
PROFESSOR & HEAD ,
DEPARTMENT OF UROLOGY,
VIMS, BELLARY.
11.2. Signature
11.5. Head of the Department
Dr. VIDYADHAR KINHAL
PROFESSOR & HEAD ,
DEPARTMENT OF SURGERY,
VIMS, BELLARY.
11.6. Signature
12
12.1. Remarks of the Chairman
and Principal
12.2. Signature