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Dr.B.BALAGOBI

LecturerDepartment of SurgeryFaculty of Medicine,UOJ

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Urology

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IntroductionAetiopathogenesisHow do they presentHow to asses a patient with stone diseaseStone related emergenciesTreatment options

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Urolithiasis is the presence of one or morecalculi at any location of the urinary tract.Incidence is 1-5% of the populationPeak age group 20-50 years of ageMen affected 3times more90%of the stones are radio opaque

Predominantly a tropical diseaseRecurrent course unless cause treated

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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

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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

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Most common (75%)Due to Renal hypercalciuriaCauses= Hyperparathyroidism, BoneMets, Ca++ absorptionOften dark brown(altered blood onsurface)

Sharp projections+

Radio opaqueEven small stones symptoms.

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Calcium oxalate dihydrates

http://www.herringlab.com/photos/Urinary/Oxalates/Cod/Cod_N.jpghttp://www.herringlab.com/photos/Urinary/Oxalates/Cod/Cod_V.jpghttp://www.herringlab.com/photos/Urinary/Oxalates/Com/Com_H.jpghttp://www.herringlab.com/photos/Urinary/Oxalates/Com/Com_Q.jpg

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Also called Triple phosphateAssociated with infections by urea splittingbacteria (Proteus)

Alkaline UrineStag-horn calculi typically large takes onshape of calyx Radio opaque

Asymptomatic for a long time latepresentation(even CRF)

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Location of Renal stones

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Stones are formed primarily at Renalcalyces/pelvis

continue to grow(stag horn calculus)

Pass down the ureter(struck@PUJ,pelvicbrim,VUJ)Urinary bladder stone(denovo)

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IdiopathicDietary factors(low fluid intake,high protein diet,highpurine,oxalate)

Hyper uricuria(gout,chemotherapy for leukaemia)Urinary stasis(PUJO,Stricture,Horse shoe kidney(reflux +),BOOChronic infection(urease producingorganisms:proteus tripple phosphate stone.

Prolonged immobility (spinal injury,paraplegia)

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Voiding dysfunction/BOO(BPH,Urethral stricture)Foreign bodyDiverticula

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PainHaematuriaClinical features of complications

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Most common presenting symptom due to obstructionUreteric stone :Ureteric colic(loin to groin/scrotum-labia majora/tip of the penis.) andNausea+,vomiting+,sweating

Renal stone Loin painbladder stone LUTS(frequency,urgency,dysuria),supra pubic pain

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Painfulusually microscopic.RBC in urine is Present in 85-90% of patientwith stone

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Infection

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

CRFStag horn/bladder calcli chronicinflammation squamous cell ca Xantho granulomatous pyelonephritis :

end stage of chronic inflammationis difficult,can be mistaken as renal tumour onimaging)Rx:ne hrectom

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Clinical assessment is importantAlways consider a differential diagnosis

Objectives of assessment1. Confirm diagnosis2. Exclude complications(sepsis,renal failure)3. Locate size and size of stone(s)4. Plan therapy

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Non urologicalAppendicitisDiverticulitis

Ectopic pregnancy,salphingitis,tortion of ovarian cystRupturedAAAbiliary colic

UrologicalPyelonephritisStricture,tumour,renal infarctionTesticular tortion

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To confirm the diagnosis :UFRXray KUB

USS/AbdCT/IVU

To find aetiologyanalysis of the stone(after passing spontaneously/After sx)

S/Ca,S/uric acid.

To look for complicationsS/cr,S/E,FBC

Imaging

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High risk patientsChildrenBilateral stonesRecurrent stonesKnown anatomic orbiochemicalanomalyLarge stonesSingle kidney

Strong familyhistory

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Relieve the pain:100mg diclofenac sodium suppository/IM pethidine75mg with antiemetic

(usually 1 or 2 doses enough) oral fluids,IV fluids collect urine &analysisfor stone

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-If stone size 6mm only 10%pass spontaneouslySo if stone

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Obstructed infected tractCalculus Anuria

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Absolute indicationUrosepsis

renal function

Relative indications:intractable painlarge stonefailure to progressionoccupation(pilots)

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ConservativeESWLUreteroscopyPercutaneous Nephrolithotomy(PCNL)Open Surgery

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Calculi Site,SizeAvailability of RxAbnormal anatomy or the urinary tractPt wish

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Small stones(

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Esp @renal pelvis,upper ureter stonenon-invasive &no need of anaesthesiamay need multiple treatmentenergy source:Electro hydraulic,Electromagnetic,piezo electricContraindication:

urosepsis,pregnancy,coagulopathy,renal arteryaneurysm/AAA

Complications of ECSWLInfection,renal haematoma,obstruction of ureter byfragments,HT,renal/Adjacent organ damage.

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AdvantagesNon invasiveUp to 2 cm renal stones

Out patient procedure

LimitationsLower pole stonesLarger stonesHard stones

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lithotripsy

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Symptomatic AsymptomaticStaghorn

< 3 cm > 3 cm

ESWL PCNL No function Functioning+

ESWL Nephrectomy PCNL+

ESWL

Young, fit

Elderly, unfit

Observe

Insert stent prior to ESWL

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Obstruction +/or Non-obstructed +/orSypmtomatic Asymptomatic

Infected Sterile

Urgent Early > 5mm < 5mmTreatment Treatment

Expectant

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Options of treatment

Upper 1/3 Middle 1/3 Lower 1/3

Push pull URS disintegration +/- URS & Dormia basketstent Ballistic lithotripsy

Push bang - USOpen - EHL

- Laser- Ballistic- Open

URS = Ureteroscopy US = Ultrasound EHL = Electrohydraulic lithotripsy

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Very large Small / Moderate

Open suprapubicTransurethralcystolithotomy litholapaxy

- Optical lithtrite

- Electrohydrauliclithotrite

- Holmium laser- Ultrasound probeTreat underlying cause

Bladder outflow obstruction Neuropathic bladder

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Treat cause if anyPlenty of waterModest dietLimit red meats, alcoholAvoid Calcium supplementsAvoid excess salt,milk products, small fish

Optimize co morbiditiesPeriodic surveillance tests

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Renal calculi A. Usually presents in the 40sB. Are usually due to hyper parathyroidismC. May be caused by enterobacteriaD. Can be treated with ECSWLE. Can be treated with percutaneous nephron

lithotomy

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Bladder calculi A. Usually arise from calculi passed down the ureterB. Occur in bladder diverticulaC. May lead to transitional cell carcinoma of the

bladderD. Can be removed endoscopically

E. May be totally asymptomatic

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Regarding ureteric calculi A. Usually leads to microscopic haematuriaB. Usually radio lucentC. All need surgical extractionD. Are most often composed of calcium oxalateE. Only 10% of stones

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Regarding ureteric calculi A. An obstructed ureter with infection is a

surgical emergencyB. Uric acid stones are radio opaqueC. Calcium oxalate stones have sharp spiculesD. Ammonium magnesium calcium phosphate

forms the stag horn calculiE. Cysteine stones are radio opaque

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Acceptable treatment options of 1cmsymptomatic stone@renal pelvis in 40 yr oldman

A. Conservative managementB. Diuretic challengeC. ECSWL

D. PCNL is the first line treatmentE. Dormia basket extraction

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Extra corporeal shock wavelithotripsy(ECSWL)

A. Is the treatment of choice for large stag horn

calculiB. Should not be used for cystine stonesC. It may be complicated by sepsis

D. It is used to treat stones in lower 1./3 of uretercommonlyE. Can be used in obstructed kidney

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