Dr.B.

BALAGOBI
Lecturer Department of Surgery Faculty of Medicine,UOJ

Urology

Introduction Aetiopathogenesis How do they present How to asses a patient with stone disease Stone related emergencies Treatment options

Urolithiasis is the presence of one or more calculi at any location of the urinary tract. Incidence is 1-5% of the population Peak age group 20-50 years of age Men affected 3times more 90%of the stones are radio opaque Predominantly a tropical disease Recurrent course unless cause treated

Lithogenic urine/ "supersaturated/Lithogenic urine

Chronic fluid deprivation
Increased excretion of salts(Ca,Po4,Uric acid,oxalate) Changes in pH Reduction of inhibitors of stone formation(citrate,

magnesium, pyrophosphate)

Stasis Foreign bodies

Stents,Catheters,Debris from devitalized

tissue,Tumor,Infection,stones

Idiopathic

1. Calcium oxalate (75%) 2. Magnesium Calcium ammonium phosphate stones (15%) 3.Uric acid (6%)

Purine metabolism high turnover of protein metabolism( in Gout, Leukemias & Lymphomas ) They are not visible on X-rays

4.Cystine (2%)

Genetic defects in reabsorption of amino acids hardstones,No ECSWL treatment

Most common (75%) Due to Renal hypercalciuria Causes= Hyperparathyroidism, Bone Mets, Ca++ absorption Often dark brown(altered blood on surface) Sharp projections+ Radio opaque Even small stonessymptoms.

Calcium

oxalate dihydrates

Also called Triple phosphate Associated with infections by urea splitting bacteria (Proteus) Alkaline Urine Stag-horn calculi typically large takes on shape of calyx Radio opaque Asymptomatic for a long timelate presentation(even CRF)

Location of Renal stones

Stones are formed primarily at Renal calyces/pelvis

continue to grow(stag horn calculus) Pass down the ureter(struck@PUJ,pelvicbrim,VUJ)

Urinary bladder stone(denovo)

Idiopathic Dietary factors(low fluid intake,high protein diet,high purine,oxalate) Hyper uricuria(gout,chemotherapy for leukaemia)
Urinary stasis(PUJO,Stricture,Horse shoe kidney(reflux+),BOO

Chronic infection(urease producing organisms:proteustripple phosphate stone. Prolonged immobility (spinal injury,paraplegia)

Voiding dysfunction/BOO(BPH,Urethral stricture) Foreign body Diverticula

Pain Haematuria Clinical features of complications

Most common presenting symptom due to obstruction Ureteric stone:Ureteric colic(loin to groin/scrotumlabia majora/tip of the penis.) and Nausea+,vomiting+,sweating Renal stoneLoin pain bladder stoneLUTS(frequency,urgency,dysuria), supra pubic pain

Painful usually microscopic. RBC in urine is Present in 85-90% of patient with stone

Infection

Hydro nephrosis,hydro ureter pyonephrosis /urosepsis Rx:IVAB+percutaneous nephrostomy

CRF Stag horn/bladder calclichronic inflammation squamous cell ca Xantho granulomatous pyelonephritis :
end stage of chronic inflammation is difficult,can be mistaken as renal tumour on imaging) Rx:nephrectomy

Clinical assessment is important Always consider a differential diagnosis Objectives of assessment 1. Confirm diagnosis 2. Exclude complications(sepsis,renal failure) 3. Locate size and size of stone(s) 4. Plan therapy

Non urological

Appendicitis Diverticulitis Ectopic pregnancy,salphingitis,tortion of ovarian cyst RupturedAAA biliary colic Pyelonephritis Stricture,tumour,renal infarction Testicular tortion

Urological

To confirm the diagnosis :

UFR Xray KUB USS/Abd CT/IVU

analysis of the stone(after passing spontaneously/After sx)

To find aetiology

S/Ca,S/uric acid.

To look for complications

S/cr,S/E,FBC Imaging

High risk patients Children Bilateral stones Recurrent stones Known anatomic or biochemical anomaly Large stones Single kidney Strong family history

Relieve the pain:

100mg diclofenac sodium suppository/IM pethidine 75mg with antiemetic (usually 1 or 2 doses enough)

oral fluids,IV fluids collect urine &analysis for stone

-If stone size

<4mm 80%pass spontaneously 4-6mm 50%pass spontaneously >6mm only 10%pass spontaneously

So if stone <5mm conservative management,to enhance this water intake,analgesics

Obstructed infected tract Calculus Anuria

Absolute indication

Urosepsis renal function intractable pain large stone failure to progression occupation(pilots)

Relative indications:

Conservative ESWL Ureteroscopy Percutaneous Nephrolithotomy(PCNL) Open Surgery

Calculi Site,Size Availability of Rx Abnormal anatomy or the urinary tract Pt wish

Small stones(<4-5 mm) More distal the better Pain controlled Absence of renal failure and sepsis Diclofenac sodium Alpha blockers Review and ensure stone has passed Absence of pain does not confirm stone expulsion

Esp @renal pelvis,upper ureter stone non-invasive &no need of anaesthesia may need multiple treatment energy source:Electro hydraulic,Electro magnetic,piezo electric Contraindication:

urosepsis,pregnancy,coagulopathy,renal artery aneurysm/AAA Infection,renal haematoma,obstruction of ureter by fragments,HT,renal/Adjacent organ damage.

Complications of ECSWL

Advantages Non invasive Up to 2 cm renal stones Out patient procedure Limitations Lower pole stones Larger stones Hard stones

lithotripsy

Symptomatic Staghorn

Asymptomatic

Young, fit

< 3 cm
ESWL

> 3 cm
PCNL + ESWL No function Nephrectomy

Elderly, unfit
Functioning Observe PCNL + ESWL

Insert stent prior to ESWL

Obstruction +/or Sypmtomatic

Non-obstructed +/or Asymptomatic

Infected

Sterile

Urgent Treatment

Early Treatment

> 5mm

< 5mm

Expectant

Options of treatment Upper 1/3

Push pull Push bang Open

Middle 1/3 Lower 1/3

URS disintegration +/- URS & Dormia basket stent Ballistic lithotripsy - US - EHL - Laser - Ballistic - Open
US = Ultrasound EHL = Electrohydraulic lithotripsy

URS = Ureteroscopy

Very large
Open suprapubic Transurethral cystolithotomy
lithotrite

Small / Moderate

litholapaxy
- Optical lithtrite - Electrohydraulic - Holmium laser - Ultrasound probe

Treat underlying cause Bladder outflow obstruction Neuropathic bladder

Treat cause if any Plenty of water Modest diet Limit red meats, alcohol Avoid Calcium supplements Avoid excess salt,milk products, small fish Optimize co morbidities Periodic surveillance tests

A.
B. C. D. E.

Renal calculi Usually presents in the 40s Are usually due to hyper parathyroidism May be caused by enterobacteria Can be treated with ECSWL Can be treated with percutaneous nephron lithotomy

A.
B. C.

D. E.

Bladder calculi Usually arise from calculi passed down the ureter Occur in bladder diverticula May lead to transitional cell carcinoma of the bladder Can be removed endoscopically May be totally asymptomatic

A.
B. C. D. E.

Regarding ureteric calculi Usually leads to microscopic haematuria Usually radio lucent All need surgical extraction Are most often composed of calcium oxalate Only 10% of stones<5mm pass spontaneously

A.

B.

C.
D.

E.

Regarding ureteric calculi An obstructed ureter with infection is a surgical emergency Uric acid stones are radio opaque Calcium oxalate stones have sharp spicules Ammonium magnesium calcium phosphate forms the stag horn calculi Cysteine stones are radio opaque

A.

B.
C. D.

E.

Acceptable treatment options of 1cm symptomatic stone@renal pelvis in 40 yr old man Conservative management Diuretic challenge ECSWL PCNL is the first line treatment Dormia basket extraction

A.

B.
C. D.

E.

Extra corporeal shock wave lithotripsy(ECSWL) Is the treatment of choice for large stag horn calculi Should not be used for cystine stones It may be complicated by sepsis It is used to treat stones in lower 1./3 of ureter commonly Can be used in obstructed kidney

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