URINARY STONES

URINARY STONES

CALCULAR DISEASE

Incidence:

Common, affecting 10-20% of population. Males affected more than females. Occurs mainly in middle age, but no age immune. 2/3 patients have recurrence within 8 years.

Aetiology:

1-Geography: tropical area, mountainous and Mediterranean countries. 2-Climate: direct relationship between temp and stone incidence. 3-low Water intake: 4-Diet: 5-Socio-economic status:


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6-Metabolic & endocrinal factors: I- Ca++ oxalate & Ca++ phosphate calculi: Hypercalcemia (hyperparathyroidism) Hypercalciuria. Hyperoxaluria: primary (congenital), secondary (enteric disease) or idiopathic (dietary). Hypocitraturia: . Hyperuricosuria: Renal tubulal acidosis: associated with hypercalciuria & hypocitraturia.

II- Uric acid calculi: Hyperuricemia and hyperuricosuria. III-Cystine calculi: hereditary cystinuria. IV-Xanthine calculi:hereditary xanthinuria

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7-Infection: UTI due to urea splitting MO (urease producing MO) causes urine alkalinazation hence phosphate precipitation. (triple phosphate stones). 8-Congenital anomalies.

Types of renal calculi

I-Calcium stones: 70%, radio-opaque. a-Calcium Oxalate Calcium oxalate monohydrate: smooth, dark and hard. Calcium oxalate dihydrate: granular, lighter in colour and fragment easily. .


b- Calcium phosphate calculi: radio opaque. They grow in alkaline urine and attain large size. Staghorn calculus. II- Triple phosphate calculi (Struvite): Grows very rapidly in alkaline urine, radio-opaque.


III- Uric acid calculi: hard, smooth and golden yellow. Pure uric acid stones are radiolucent.

Symptoms:

1-Asymptomatic. 2-Loin pain. 3-uretric colic. 4-Hematuria. 5-Infection or pyuria. 6-Renal failure.

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Investigations

1- GUE: microscopic hematuria 90%, sterile pyuria and crystalluria. 2- U/S : stone shadow, hydronephrosis and hydroureter. The whole ureter cannot be visualized. 3- KUB: 90% radio-opaque & soft tissue shadow of hydronephrotic kidney.

Differential diagnosis of radio opaque shadow in KUB

Gall stone, calcific LN, FB, phlebolith, fecolith, calcified TB lesion, chip # of transverse process, calcified rib tip, calcified fibroid and ovarian dermoid cyst.


4- IVU:
Hydronephrosis, renal function, site of obstruction and filling defects in radiolucent stones. 5- Retrograde pyelography 6- CT scan & MRI: 7- Endoscopic: urethroscope, cystoscope, ureteroscope and nephroscope


KUB

Management of urinary stones

Aims: Relief pain and colic. Eliminate or stone removal. Prevention of recurrence.

‘ Renal colic: strong analgesia, NSAID (Diclfenac 75 mg im) or narcotics (Pethidin 50-100 mg im). Hydration in dehydration. Antibiotics in renal infection. Hospitalization may be needed.

Methods of treatment of renal stone:

conservative treatment -Extracorporeal shock wave lithotripsy (ESWL). Ureteronephroscopy with laser -Percutaneous nephrolithotomy (PCNL). -Combination.like ESWL AND PCNL -Open surgery. -Chemolysis.

Conservative treatment

Stones less than 5mm have 50% chance of spontaneous passage. High fluid intake,after pain relief and follow up by KUB ,ULS.CT.

ESWL

Indications: all stones less than 2 cm in the kidney and ureter. Contraindications: large stones, bleeding tendency, , ureteric obstruction, renal insufficiency, pregnancy, skeletal anomaly and overweight.


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Complications of ESWL:

Failure of stone fragmentation. Hematuria. Ureteric colic. Ureteric obstruction (stone street). Infection. Rapid recurrence due to residual fragments.

Indication of jj stent in ESWL

LARGE STONE STONE IN A SINGLE KIDNEY

PCNL:

Using lithotripter through percutaneous nephroscope to retrieve the renal stones.

PCNL

Advantages
*Small endoscopic wound *Mild post operative pain. *Short hospital stay.

Open surgery

Indications: If ESWL or PCNL are contraindicated or failed.

Methods:

Pyelolithotomy. Nephrolithtomy. Pyelonephrolithotomy. Partial nephrectomy. Nephrectomy.

Dissolution agentschemolysis

oral alkalinizing agents for uric acid & cystine stones Acidification in struvite tone

Methods of ureteric stones treatment

Conservative ESWL Ureteroscopic lithotripsy Ureterolithotomy. open laparoscopic

Expectant treatmentconservative

is appropriate for small stones. Spontaneous passage depends on stone size, shape, location . Ureteral calculi 4-5 mm in size have a 40-50% chance of spontaneous passage. In contrast, calculi > 6 mm have a less than 5% chance of spontaneous passage.

Sites of stone impaction

1-Pelviureteric junction. 2-Pelvic brim. 3-Ureterovesical junction.

Conservative treatment for ureteric stone

Analgesic for colic NSAID Antibiotic for infection Encourage fluid intake Alfa blocker Follow up by KUB,ULS,CT SCAN

Indications for intervention

Repeated attacks of pain &the stone is not progressing. Stone is enlarging with time. Complete obstruction of the kidney. Symptoms & signs of infection. Stone is obstructing solitary kidney or there is bilateral obstruction. Impaired renal function( elevated urea & creatinine).

Ureteroscopic Stone Removal Small stones removed as one piece using forceps under direct vision. Large stones are fragmented using pneumatic, electrohydraulic , or Laser Lithotripter then removed in pieces.

Dormia Basket should only be used for small stones removal by cystoscope or preferably by ureteroscope

Ureterolithotomy

Open Ureterolithotomy Laparoscopic Ureterolithotomy

Urinary bladder stone: (vesical)

Etiology: Children: dehydration, low protein diet & UTI Adult: 1- Urinary obstruction: BPH & stricture. 2- UTI. 3- Neurogenic bladder dysfunction. 4- Foreign body.

Clinical pictures

1-Pain: suprapubic pain, penile pain especially at the tip of the penis or labia majora at the end of micturition. 2-Frequency of urination. 3-Difficulty in micturition or retention of urine. 4-Hematuria.



Treatment of Vesical Stone
Treat the underlying cause. Cystolitholapaxy (Endoscopic) :Its minimally invasive technique allowing most stones to be broken and subsequently removed through a cystoscope...stone crushing by electrohydraulic, ultrasonic, laser, and pneumatic lithotrites . Mechanical lithotrites (stone punch) & Elik evacuator. Suprapubic cystolithotomy Laparoscopic cystolithotomy ESWL

Vesical stones treatment

IN CHILDREN Suprapubic cystolithotomy ,

Urethral stones

Origin: Most often migrated from the ureter and arrested in the prostatic or bulbous urethra Less commonly originated in the urethral diverticulum (Ca++ phosphate)

Clinical pictures

*Severe urethral pain during urination. *Interruption of urine stream. *Retention of urine. *Urethral ex.:induration of the stone. *Click felt by metal bougie.

Treatment of urethral stone

Treat the underlying cause. Small stones may be grasped successfully and removed intact. pushed back to the bladder,and trated as vesical stone. Long-standing, large impacted stones are best removed through a urethrotomy.