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Surgery Essay

Outline the management of a 70-


year old man with a 3cm stone in
the bladder.

IN an acute presentation, were there has been ureteric


obstruction by a bladder stone and acute urinary retention, the
patient will present with agonising suprapubic pain. Analgesia
such as diclofenac 100mg PR is given together with an
antiemetic such as metroclopramide 10mg IV. The patient is
supplemented by IV fluids. Since this patient does not have a
small stone, he cannot be managed expectantly because it is
unlikely he will pass the stone spontaneously.

Extra-corporeal shock-wave lithotripsy (ESWL) is most


likely to be used. This involves focused, externally generated
electro hydraulic or ultrasonic shockwaves. Using ultrasound, X
ray or a combination of both the ESWL can be targeted on the
calculus. This will cause stone disintegration and the fragments
are then voided. This avoids removal of stones from the renal
tract as an open operation which prevents a lot of problems in
an elderly male. The elderly have multiple co morbidities, which
are often silent due to atypical presentation or underreporting
of symptoms. Also an elderly male might be prone to mild or
moderate malnutrition increasing surgical complication rates. In
addition a 70- year old male might have reduced or acutely
impaired mental faculties and this may make operation consent
taking difficult.
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Surgery Essay

To prevent recurrence, advice must be given to the patient and


his family and carers. This includes an increase in his oral
intake and to reduce calcium intake as 75% of all urinary
tract stones are calcium stones. Any metabolic abnormality,
such as hyperparathyroidism, sarcoidosis and hypervitaminosis
D, needs to be corrected as these are aetiological factors for
stone formation. Infection is another aetiological factor;
therefore if it is treated promptly, there is prevention of
recurrence. Urinary alkalization, e.g. Sodium bicarbonate or
potassium citrate 5-10mg/24hr PO in water is useful to prevent
the recurrence of cystine and urate stones. If there is a high
urate in blood, allopurinol is useful to block its synthesis via
xanthine oxidase. Thiazide diuretics are useful for idiopathic
hypercalciuria.

27/01/09