URINARY STONES
CALCULAR DISEASEIncidence:
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:!
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.-
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.
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.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 nephroscopeKUB
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.
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.Methods of intervention:
1-Extracorporeal shock wave lithotripsy (ESWL). 2-Percutaneous nephrolithotomy (PCNL). 3-Open surgery. 4-Chemolysis. 5-Combination.like ESWL AND PCNL Ureteronephroscopy with laserESWL
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.‘
Complications of ESWL:
Failure of stone fragmentation. Hematuria. Ureteric colic. Ureteric obstruction (stone street). Stone in single kidney needs JJ stent. Infection. Rapid recurrence due to residual fragments.
Indication of jj stent in ESWL
LARGE STONE STONE IN A SINGLE KIDNEYPCNL:
Using electrohydrulic 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 agents chemolysis
oral alkalinizing agents for uric acid & cystine stones Acidification in struvite toneMethods of ureteric stones treatment
Conservative ESWL Ureteroscopic manipulation. Dormia basket stone extraction. Ureterolithotomy. open laparoscopicExpectant treatment conservative
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.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 too large to pass. 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