Done by : Thukaa al- qanahera - PowerPoint Presentation

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Done by : Thukaa al-qanaheraMuntaha al-khazaaleh

STONE DISEASE

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Calculi are typically composed of urinary chemicals that are usually soluble in urine but occur in amounts too high to stay dissolved Stones could be described according to the site (kidney, bladder, ureter, urethra) or radiodensity on KUB (radio opaque, radiolucent, relatively radiolucent) or the size and composition

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Calcium oxalate ..80%Uric acid …5-10%Calcium phosphate …10% mostly mixedStruvite …2-20%Cystine…1%Others as drug induced

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pathogenesisThe solution is considered saturated when reach the point at which the added salt crystals will not dissolveThe concentration at this point is called saturation product,

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In urine despite the concentration of stone forming component exceed the solubility product crystallization not necessary happen because of presence of inhibitersIn this state of saturation the urine is considered metastableconcentration at which no longer mount of crystal be dissolved and crystallization will happen is called formation productthe urine above formation product is considered unstable

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If urine is under saturated (below the solubility product )  crystals will not formIf urine is unstable (above formation product)  crystals will formIf urine is metastable (between the both product ) inhibiters will prevent crystallization in most of time

Under certain circumstances crystal will form if urine is metastable , first if there is

obstruction

in upper urinary tract, second

heterogeneous nucleation

presence of abnormal substance favor the crystal formation

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pathogenesisIn normal urine the solubility of calcium oxalate is 4 times higher than it’s solubility in waterThis is because various inhibiters of crystallization (citrate ,GAG , Tamm-Horsfall protein) The earliest phase of crystal formation is :1. nucleation ,then 2. aggregation process will start

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EpidemiologyThe lifetime prevalence of kidney stones is 8.8% in USAThe peak incidence of stone disease is between (20-50) yearsGender: male to female ratio 1.4:1Race: the highest prevalence of stone disease is between the whitesPrevalence: proportion of persons who have a condition in particular time

Incidence:

proportion of person who develop a condition in particular time

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Geography: stone disease has higher prevalence in hot and dry climate, however the genetic and dietary influences outweigh the effect of geographyOccupation: workers who exposed to high temperature have higher risk of stone disease, also individual with sedentary occupation has higher risk of unknown reason.

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Obesity: obesity associate with increase excretion of oxalate and uric acid, also associate with lower urine PH.Diet: high protein intake (high urinary oxalate),high salt intake cause hypercalciuria , low calcium diet Water: high water intake decrease the incidence of stone disease

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Calcium oxalate stone Calcium oxalate causes : dehydration, hypercalciuria, hyperoxaluria

,

hypernatrituria

,

hypocitraturia

hyperuricosuria

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Hypercalciuriaincrease absorption from GI like in high level of VIT D renal hypercalciuria : impaired renal reabsorption of calcium and so increase renal excretion of calcium, lasix(furosmide) inhibit calcium reabsorption and so hypercalciureaResorptive

hypercalciuria

: primary hyperparathyroidism lead to excessive bone

resorption

and so high level of

calcium

Drugs

: steroid increase bone

resorption

and reduce bone formation

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Hyperoxaluriaprimary oxaluria which is rare autosomal recessive disorder associate with high level of oxalateEnteric hyperoxaluria : fat malabsorption leads to increase the attachment of fat with calcium and so more free oxalate and increase it,s absorption like in IBD and enteric bypassDietary hyperoxaluria: like chocolate and nuts, VIT C intoxication

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Hypocitraturia: metabolic acidosis reduce urinary citrate levelHyperuricosuria: is associate with calcium oxalate stone by unknown mechanism and associate with uric acid stone , the most common cause is high dietary intake (meat) , gout and multiple myeloma, post chemotharapy

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Uric acid stone The three main determinant of uric acid formation : low PH, low volume, hyperuricosuriaUrin PH is a critical factor in determining uric acid solubility, uric acid is less soluble in acidic urine (low PH),

DM and obesity is associated with low urinary PH

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Cystine stonecystinuria is inherited autosomal recessive disorder characterized by decrease renal reabsorption of cystine amino acid

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Infection stoneStruvite = infection = triple phosphate stone is composed of magnesium ammonium phosphateBacterial urease convert urea into ammonia and carbon dioxideThis will result to alkaline urine which favor conversion of ammonia into ammoniumThe alkaline condition also increase concentration of phosphate

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Proteus is the most common organism associate with infection stoneE coli rarely secretes ureaseInfection stone is more in female

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Calcium phosphate stone Distal renal tubular acidosis (type 1): inability to acidify the urine inspite of metabolic acidosis, due to abnormal collecting duct secretion of acidAcetozolamide (carbonic anhydrase inhibiter diuretic): block bicarbonate absorption and so alkaline urine wthe calcium phosphate stoneCharacterize by hypokalemia and hyperchloremia, metabolic acidosis and alkaline urine , calcium phosphate stone and nephrocalcinosis

,

hypocitraturea

,

hypercalciurea

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Urinary obstruction such as PUJS and hors shoe kidney associate with stasis and infection and so increase incidence of stoneMedullary sponge kidney: ectasia of renal collecting duct which associate with distal RTA and hypercalciureaNOTES

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Kidney stonesMay present with symptom or found incidentallySymptoms include :Pain ( acute colicky flank pain radiating to the groin or socrotum ) Hematurea Often associated with nausea and vomiting Infection stone

present with recurrent UTI, or infection complication

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KUB : exposure from level of diaphragm to inferior pubic ramus, stone is classified according to appearance on KUB into:Radio opaque: calcium phosphate and calcium oxalateRelatively radiolucent: struvite, cystineRadiolucent: uric acid , indinavir

Radiological assessment of kidney stone:

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Radio-opaque

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Semi-radiolucent

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Limitation : stones could be obscured by overlying gas or bone, pelvic calcification could confused with ureteral stone, radiolucent stone does not appear on KUB

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stones can be characterised by their size and shape on KUBStone that occupy the renal pelvis and one or more renal calyces is called staghorn stone, which mostly composed of infection stone

Limitation :

stones could be obscured by overlying gas or bone,

pelvic calcification could confused with ureteral stone,

radiolucent stone does not appear on KUB

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staghorn stone3- size , staghorn stone ….

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Renal ultrasound : sensitivity to identify renal stone is variable, operator dependent CT scan without contrast : the modality of choice to detect renal stoneIt is more sensitive than KUB and provide anatomical information about the kidney and degree of HN

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radiolucent

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Small asymptomatic stone in older age group could be managed by watchful waitingStruvite stone is not suitable for watchful waiting because the risk of RI and sepsis.The minimally invasive modality for stone fragmentation include SWL,URS,PCNLDeciding the best treatment option depends on stone related factors, anatomical factors, clinical factors

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Treatment1- Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break a kidney stone into small pieces that can more easily travel through the urinary tract and pass from the body.**extracorporeal fragmentation of stone effects depend on stone size, location, anatomy of collecting system, and stone composition

**ESWL

is

less effective in stone >

1 cm ,lower pole stone or calyceal diverticulum stone

, cystine stone and obese patient

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2500 - 3000 impulses per procedureSide effect of ESWL : hematurea or perirenal hematoma , cardiac arrhythmia

ESWL is contraindicated in:

Pregnancy

Bleeding tendency

Arterial aneurysm near the stone

Obstruction distal to the stone

Skeletal malformation

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ESWL

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Extracorporeal Shock Wave Lithotripsy

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2- Flexible ureteroscopy and laser :- in ESWL failure or contraindicated , in lower pole stone less than 1 cm with un favorable factors such as obesity, and hard stone ( cystine stone)

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3- Percutaneous NephroLithotomy (PCNL) : is the preferred technique for treating larger kidney stones (over 2cm in diameter) located within the kidney , lower pole stone more than 1 cm, failed other modalities and anatomic abnormality ** It involves keyhole surgery that is performed through a 1cm incision in the skin ** The first line treatment in staghorn

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PCNL

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4-laparoscopic or open pyelolithotomy rarely done

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medical therapy ( dissolution therapy) :uric acid stone are suitable for dissolution therapyDissolution therapy is based on hydration, urine alkalinization with potassium citrate, and allopurinol** Allopurinol inhibit xanthine oxidase and so decrease the level of uric acid

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Ureteric stonePresentation : ureteric colic, fever, hematuria, and RFAcute management of ureteric colic is analgesia with narcotic or NSAID better analgesic effect because it reduce the GFR and so the dilatationConservative management involve analgesia for pain exacerbation and medical expulsive therapy and waiting the stone to pass spontaneously.Example of MET alpha 1 blocker and calcium channel blocker.

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Factors that favor the passage of stone :Stone less than 5 mmLower ureteric stone Less duration of symptomLess degree of HN

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Indication of urgent intervention to relieve obstruction or remove the stone :Pain not responding to analgesiaFever (obstructive pyelonephritis): jj stent vs nephrostomyImpaired renal function: single kidney or bil ureteric obstructionProlonged unrelieved obstruction: more than 4 weeks

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Methods to relieve the obstruction:Jj stentnephrostomy

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JJ stent

A

ureteric

 stent (also called a 

J-J stent

 or 

double-J stent

) is a thin, flexible plastic tube which is curled at both ends to avoid damaging the kidney and urinary bladder and to prevent it from dislocating. The stent is placed so that its upper end is in the kidney and its lower end is in the urinary bladder.

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Nephrostomy

A 

nephrostomy

 is an artificial opening created between the kidney and the skin which allows for the urinary diversion directly from the upper part of the urinary system (renal pelvis). An

urostomy

is a related procedure performed more distally along the urinary system to provide urinary diversion.

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Upper ureteric stone

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Middle ureteric stone

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Lower ureteric stone

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CTKUB

A 

CT KUB

 (computed tomography, kidneys,

ureters

and bladder), is the investigation of choice for acute renal colic. This is a study without intravenous or oral contrast, relatively low dose (in CT terms), and has a very high sensitivity for the detection of renal and

ureteric

stones.

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Treatment** Treatment option for ureteric stoneESWL: good option for upper ureteric stone less than 1 cm in sizeUreteroscopy : semi rigid URS with intra corporeal fragmentation of the stone

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** if more than 5mm according to size and sites:-More than 10 mm whatever site best TX ureteroscopy and intracorporal lithotripsyLess than 10 mm upper ureter.. Best Tx ESWLLess than 10 mm mid ureter .. Best Tx URS

Less than 10 mm lower ureter .. Best Tx

URS

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Intracorporal lithotripsy1- pneumatic lithotripsy :- bursts of compressed air, safe, but stone migration2- Ultrasonic lithotripsy:- break and suck stones, used in PCNL3-Laser lithotripsy:- by photo thermal mechanism so stone vaporization, less stone migration

4-Electrohydraulic

lithotripsy:-

Narrow safety margin,

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Evaluation of stone former low risk stone former:**History about underlying condition, medication, diet and fluid intake** CBC and KFT with electrolyte, calcium, PTH, uric acid, urine test for infection and PH** Radiography** Stone analysis

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High risk stone former:Recurrent stone formerStrong family historyGoutOsteoporosisSingle kidneyInflammatory bowl diseaseInfection, cystine, uric acid stone** Workup for high risk stone former include: 24 hour urinary collection for calcium, oxalate, uric acid, cystine, and evaluation for RTA with the basic work up for low risk

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Dietary recommendation of stone former:Increase in fluid intake( urine output at least 2 litersProtein and salt restrictionAvoidance of oxalate( chocolate and nuts)Moderate calcium intake

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Bladder stone- mostly struvite ( infected) or uric acid (non infection)Tx according to size :-** if less than 3cm .. Cystolitholapaxy** if more than 3 cm .. Cystolithotomy- Occur in chronically catheterize patient or in BPH

Patients

with

bladder

stones

frequently

give

a

history

of

hesitancy,

frequency,

dysuria

,

hematuria

,

dribbling,

or

chronic

urinary

tract

infection

unresponsive

to

antimicrobial

drug

therapy.

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Thank you