UROLITHIASIS

Mwashambwa
 OVERVIEW
INTRODUCTION
EPIDEMIOLOGY
CLASSIFICATION
PATHOGENESIS
CLINICAL FEATURES
INVESTIGATIONS
TREATMENT MODALITIES
COMPLICATIONS
PREVENTION
 INTRODUCTION
Urolithiasis, kidney stones, renal stones, and renal calculi are used
interchangeably to refer to the accretion of hard, solid, nonmetallic
minerals in the urinary tract
Passage of a urinary stone is the most common cause of acute
ureteral obstruction
The pain may be some of the most severe pain that humans
experience
Complications of stone disease may result in severe infection; renal
failure; or, in rare cases, death.
Urinary stones have afflicted humankind since antiquity
The earliest recorded example being bladder and kidney stones
detected in Egyptian mummies dated to 4800 BC
The specialty of urologic surgery was recognized even by
Hippocrates, who wrote, in his famous oath for the physician,
"I will not cut, even for the stone, but leave such procedures to the
practitioners of the craft (obviously, Hippocrates was not a
urologist!!)
 EPIDEMIOLOGY
The prevalence of urinary tract stonedisease is estimated to be 2% to 3%.
Rare in Blacks; Commoner in Whites and Asians
The likelihood that a white man will develop stone disease by age 70
years is about 1 in 8.
The recurrence rate without treatment for calcium oxalate renal stones is
about
10% at 1 year
35% at 5 years, and
50% at 10 years
Male : Female ratio is 3:1
Peak at 20-40 years old
Ingestion of excessive amounts of purines ,oxalates,calcium, phosphate,
and other elements often results in excessive excretion of these
components in urine
A low fluid intake, with a subsequent low volume of urine production,
produces high concentrations of stone-forming solutes in the urine.
This is an important environmental factor in stone formation .
 EPIDEMIOLOGY ctd
Disease associated with stone formation:
Hyperparathyroidism
renal tubular acidosis
(partial/complete) Anatomical abnormalities
jejunoileal bypass associated with stone formation:
Crohns disease,
intestinal resection tubular ectasia (medullary
malabsorptive conditions sponge kidney)
sarcoidosis pelvo-ureteral junction
Hyperthyroidism
obstruction
Medication associated with stone calix diverticulum
formation:
calcium supplements
calix cyst
vitamin D supplements ureteral stricture
Acetazolamide vesico-ureteral reflux
ascorbic acid in megadoses ( > 4
g/day), horseshoe kidney
Sulphonamides ureterocele
Triamterene
indinavir
 CLASSIFICATION
Calcium Stones 70-80%
Ca Phosphate 5-10%
Ca Oxalate/Phosphate 30-45% (Mixed)
Ca Oxalate 20-30%
Struvite stones 15-20%
Cystine stones -3%
Uric acid stones
 CLASSIFICATIONctd
COMPARATIVE INCIDENCES OF FORMS OF URINARY LITHIASIS

Stone analysis in Percentage

Form of Lithiasis India USA Japan UK

Pure Calcium Oxalate86.1 33 17.4 39.4
Mixed Calcium Oxalate and 4.9 34 50.8 20.2
Phosphate
Magnesium Ammonium 2.7 15 17.4 15.4
Phosphate (Struvite )
Uric Acid 1.2 8.0 4.4 8.0
Cystine 0.4 3.0 1.0 2.8
 CLASSIFICATIONctd
Oxalate (Calcium Oxalate)
Also Called Mulberry Stone

Covered With Sharp Projections

Sharp Makes Kidney Bleed (Haematuria)

Very Hard

Radio Opaque

Under microscope looks like Hourglass or Dumbbell

shape if monohydrate and Like an Envelope if Dihydrate
 CLASSIFICATIONctd
Phosphate stones
Usually Calcium Phosphate
Sometimes Calcium Magnesium Ammonium Phosphate Or
Triple Phosphate
Smooth Minimum Symptoms
Dirty White
Radio Opaque
Calcium Phosphate also called Brushite appears like Needle
shape under microscope
In Alkaline urineEnlarges rapidlyTake the shape of
CalycesStaghorn
 CLASSIFICATIONctd
Uric Acid & Urate Stone
Hard & Smooth
Multiple
Yellow or Red-brown
Radio - Lucent (Use Ultrasound)
Under microscope appear like irregular plates or
rosettes
 CLASSIFICATIONctd
Cystine Stone
Autosomal recesive disorder
Usually in Young Girls
Due To Cystinuria -
Cystine Not Absorbed by Tubules
Multiple
Soft or Hard can form stag-horns
Pink or Yellow
Radio-opaque
Under microscope appears like hexagonal or
benzene ring
 PATHOGENESIS
more than 1 of 3 general mechanisms is likely
to be active
the possible presence or abundance of substances
that promote crystal and stone formation
a possible relative lack of substances to inhibit
crystal formation;
a possible excessive excretion or concentration of
salts in the urine, which leads to supersaturation
of the crystallizing salt.
The greater the degree of supersaturation, the
greater the rate of growth of the calculi
 PATHOGENESISctd
Stasis or anatomic factors can also contribute to
the development of stone disease.
~ 85% of calcium stones are idiopathic, or primary.
Idiopathic hypercalciuria occurs in more than one half of
patients with calcium oxalate stones.
The remaining 15% of calcium stones are secondary to
some discernible etiology, most commonly,
hyperparathyroidism
Renal tubular acidosis (RTA) is an additional fairly
common secondary cause of calcium stones
Immobilization of an individual causes rapid mobilization
of the calcium in bones, and this is an important
mechanism in patients with spinal cord injury
 PATHOGENESISctd
Magnesium ammonium phosphate
(struvite) stones account for approximately
10-20% of urinary stones.
Sometimes they form complex with calcium
phosphate.
Struvite stones are caused by urea-splitting
bacteria such as Proteus, Klebsiella, and
Pseudomonas species.
Combined obstruction and infection frequently
cause renal destruction and, potentially, renal
failure if both kidneys are affected
 PATHOGENESISctd
Uric acid stones account for 5-10% of urinary
stones, Predisposing factors include
acidic concentrated urine,
excess urinary uric acid,
small-bowel disease or resection,
gout, and cell lysis
Treatment and prevention for these stones is
alkalinization and dilution of the urine.
Cystine stones account for only
approximately 1% of urinary stones.
result from cystinuria (a rare autosomal recessive
metabolic disorder),
 PATHOGENESISctd
Miscellaneous Stones
Triamterene Stones
potassium sparing diuretic
70% excreted in urine
pure stone or nidus for CaOx/UA
Indinavir Stones
greatest incidence of protease inhibitors
mean duration to stone 21.5 wks (6-50)
19% unchanged in urine
fan shaped or starburst crystals
not seen on IVU or CT
 CLINICAL FEATURES
Renal/Ureteral Colic (PAIN)
Abrupt onset while asleep or at rest
Crescendo of extreme pain
Flank radiating laterally and downward to
groin/testicle or round ligament/labia majora
Impossible to be still
Mid ureter
lateral flank and abdomen
Lower ureter
suprapubic and urethral
urgency and frequency
 CLINICAL FEATURESctd
GI Symptoms
Nausea and vomiting autonomic n.s.
Ileus or diarrhea
DDX: gastroenteritis, appendicitis, colitis,
diverticular disease and salpingitis
Hematuria
gross or microscopic
15% no hematuria!
Pyuria/Fever
Pyuria even without infection
Infection especially in females
 CLINICAL FEATURESctd
History
Duration, characteristics, and location of
pain
History of urinary calculi
Prior complications related to stone
manipulation
Urinary tract infections
Loss of renal function
Family history of calculi
 INVESTIGATIONS
Urinalysis- haematuria ~ 85% of pts
FBP
elevated WBC = renal/ systemic inf.

low RBC= xnic dse/ sev. haematuria

serum eletrolytes, creatinine, calcium, uric acid,
phosphorus: to asses renal function and
metabolic risk factors for stone formation
24 hr urine collection for pH, Ca, oxalate, uric
acid, Na, phosphorus, citrate, magnesium,
 INVESTIGATIONctd
Plain abdominal radiograph
KUB for assessing total stone burden ,the size, shape, and
location of urinary calculi in some patients.
Calcium-containing stones (~85% of all upper urinary tract
calculi) are radiopaque,
Pure uric acid, indinavir-induced, and cystine calculi are
relatively radiolucent on plain radiography
Renal ultrasound
IVU
determine the size & location

anatomical & functional assessment

Helical CT-scan without contrast
INVESTIGATIONSctd

CALCULUS IN LT
KIDNEY LOWER POLE
INVESTIGATIONSctd

STAGHORN CALCULUS
TREATMENT MODALITIES

MEDICAL

SURGICAL
 MEDICAL RX
The cornerstone of management of ureteral colic is analgesia
Morphine sulfate is the narcotic analgesic drug of choice for
parenteral use.
Antiemetic agents [metoclopramide ] may also be added as
needed.
The calcium channel blocker[ nifedipine] relaxes ureteral
smooth muscle and enhances stone passage
The alpha blockers, [ terazosin], also relax musculature of the
ureter and lower urinary tract, markedly facilitating passage of
ureteral stones
Uric acid and cystine calculi can be dissolved with medical
therapy
stones are dissolved with alkalinization of the urine.
Sodium bicarbonate can be used as the alkalinizing agent
 MEDICAL RXctd
High Fluid Intake and Alkalinized Urine dissolve
most of the smaller cystine stones
D-Pencillamine or MPG
(Mercaptopropionylglycine) binds to cystine that
is soluble in urine
Side effects of Pencillamine restricts it use
Allergic rashes, GI problems- Nausea, Vomiting,
Diarrhoea
MPG better tolerated
Large obstructive stones Surgery required first
 SURGERY
Extracorporeal Shock Wave
Lithotripsy (ESWL)
Percutaneous Nephrolithotomy (PNL)
Ureteroscopy
Open surgery

Choice of approach depends on stone

burden (size and number), stone
composition, and stone location.
 ESWL
Shock waves generated under water can travel through body
without any appreciable loss of energy.
When they encounter stones, the changes in density causes
energy to be absorbed and reflected by the stone.
This results in fragmentation of the stones.

Before lithotripsy the stone is localized by either Ultrasound or

Flouroscopy.
Complications:
Haematuria is quite common (hemorrhage and edema
within or around the kidney)
Incomplete stone Fragmentation & Obstruction;
Stienstrasse ( stone street ) usually due to a large
Leading fragment ( Stents Recommended prior to ESWL for
Calculi > 1.5 cm )
ESWL
Steinstrasse (Stone street)
- post ESWL
 PNL
Percutaneous approach allows stone removal with less morbidity,
shorter convalescence, and reduced cost compared with open
techniques
PNL has replaced open surgical procedures for removal of large or
complex renal calculi at most institutions
PNL can be performed with general, epidural, or local anesthesia
The kidney should be approached from below the 12th rib to reduce
the risk of pleural complications
The position of the retroperitoneal colon is usually anterior or
anterolateral to the lateral renal border. Therefore, risk of colon injury
is minimal
The liver and spleen may also be at risk of injury during percutaneous
access. However, in the absence of splenomegaly or hepatomegaly,
injury to these organs is extremely rare with a puncture below the 12th
rib
Once the point of puncture and the preferred calyx have been
selected, a C-arm fluouroscope is entered. The tract is dilated by
special dilators
The urologist can proceed with stone removal using endoscopic
techniques e.g with Randall's forceps, a grssper or stone baskets under
fluoroscopic guidance
 PNL. Ureteroscope
There is a concurrence in the literature regarding the need for
postoperative drainage with a nephrostomy tube after
percutaneous procedures.
The main function of a nephrostomy tube is the drainage of urine
and possibly the tamponade of bleeding originating from the
structures acutely expanded during dilatation.

URETEROSCOPY:
A ureteroscope is passed through the ureteral orifices
It is performed under general or regional anaesthesia
Once the stone is visualized, fragmentation with of the stone can be
done with laser, or mechanically
If significant ureteral edema or manipulation occurs, a stent should
be placed to prevent colic and obstruction
 Open surgery
Generally indicated for large stones that would
require multiple ESWL or PNL
obese patients are poor candidates for ESWL and
may be difficult to manage with PNL; Open
surgery might be the best option
Open surgery may be
Pyelolithotomy
Nephrolithotomy
Ureterolithotomy
Cystolithotomy
 Summary
Depending on the location of the stone, various
procedures are done for stone extraxtion
In the kidney
ESWL
PNL
Open methods
Pyelolithotomy for a stone in the extrarenal pelvis
Nephrolithotomy for a stone deep into the renal parenchyma
Partial nephrectomy if there is a stone impacted into the lower
most calyx
In the ureter
Upper ureter: ESWL is ideal
Mid ureter: ESWL, ureteroscopy or ureterolithotomy
Lower Ureter: Ureteroscope or ureterolithotomy
 Summary
In the Bladder
Litholapaxy:
through a cystoscopy, the stone is grasped firmly and
broken. Small fragments are evacuated by evacuator
Suprapubic cystolithotomy
if the stone is too big or too hard
 Complications
Ureteral scarring and stenosis
Nidus for infectionserious infection
of the kidney that diminishes renal
function
Urinary fistula formation
Ureteral perforation
Extravasation
Urinary outflow obstruction
hydronephrosisCRF
 Prevention
High Fluid Intake
Restrict Salt
Avoid high intake of purine food
Increased citrus fruits may help
If hypercalciuria restrict Ca intake
Thanks