Urolithiasis Dr.Saleh Abuorouq,MBBS - PowerPoint Presentation

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Urolithiasis

Dr.Saleh

Abuorouq,MBBS

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Definition and Incidence

Stones;

Solid concretion or calculi(crystal aggregations) formed in the kidney from dissolved urinary materials

.

The

3

rd

most common disease in urology exceeded by UTI and BPH.

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Pathogenesis of stones :

Supersaturation

of the urine by stone-forming constituents

Chemical composition

of urine that favors

stone crystallization.

Impairment

of inhibitors

that prevent crystallization in normal urine…

These inhibitors include:

 Organic:

Glycosaminoglycans

,

Nephrocalcin

.

 Inorganic: Mg, Pyrophosphate, Citrate

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Etiology :

Metabolic Problems

Non Metabolic Problems

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Metabolic Problems :

1-

Heper

calciuria

2-

Hyper

calcemia

3-

Hyper

uricemia

4-

Hyper

oxaluria

5-

Hypo

citraturia

6-

Cystinuria

(

is

an inherited

 

autosomal

 recessive 

disease )

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Non Metabolic Problems:

*

Anatomical

causes and Primary

renal

diseases

-

strictures ,

stenosis , congenital anomalies - Polycystic kidney disease. - Renal tubular acidosis type 1(distal). Ca phosphate * Infections Urease-producing bacteria(Proteus , Klebsiella )* Drugs: - Ca stones: Loop diuretics, antacids, glucocorticoids, theophylline, Vitamins D & C, acetazolamide. - Uric acid stones: Thiazides and salicylates.*Previous history of Urolithiasis.* Family history of Urolithiasis.

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Risk factors

Male sex

Obesity

White people

Warm climates

Family History

H/o stone disease (1/2 will have recurrence)

Dietary factors

Lower fluid intake, higher animal protein, higher Vitamin C, high NA intake

Medical

factors (DM,gout…..)

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Types of stones :

Oxalate calculus (calcium oxalate)

Most common (80-85%)

.

Irregular in shape

and covered with

sharp projections

, which tend to cause

bleeding

. The surface of the calculus is discolored by altered blood. A

calcium oxalate monohydrate stone is hardest stone and all calcium containing stones are radio dense ( radio-opaque ) by KUB

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Struvite

stones (10-15%)

calcium

phosphate often with

magnesium ammonium phosphate MAP

(

struvite

)

(infectious)

is smooth and dirty white. It tends to grow in alkaline urine, especially when urea-splitting (Proteus) organisms are present. The calculus may enlarge gradually to fill most of the collecting system, forming a staghorn calculus.

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Uric acid

calculi

These are

smooth and often multiple

. They vary from yellow to

reddish brown and sometimes have multifaceted appearance

.

Formed in acidic urine

Less than 5%

Pure uric acid stones are radiolucent

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Cystine

calculus

- These uncommon stones(1-2%) appear in the urinary tract of patients with a congenital error of metabolism of

cystine,ornithine,lysine

and

arginin

amino acids (COLA)in form of

malabsorbtion

that leads to

cystinuria

. Hexagonal, translucent, white crystals of cystine appear only in acidic urine. They are often multiple Cystine stones are faint radio-opaque because they contain sulphur, and they are very hard. (one of the hardest stone)

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Presentation……..

- flank pain (renal pain or

ureteric

colick

) –distention of renal capsule

- nausea and vomiting

(

vagus

nerve stimulation)

- fever -hematuria -renal impairment

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Physical exam…….

-vital signs

-general

-abdomen

-Renal angle(CVA)

-bimanual

examination

-scrotal exam (if male)

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Case

A 32-year-old female presented to the emergency room with a chief complaint of right flank pain for 7 hours in duration. The pain was sudden in onset, she described it as 'knifelike', intermittent , radiating to the right groin, it wasn’t aggravated by movement , no relieving factors .

the pain was associated with nausea but no vomiting , fever (37.6) , no history of trauma . No dysuria ,no hematuria

, no chills , she had a history of stone passage last month .

Past surgical

hx

: free

Past medical

hx

: freeFamily hx : no family hx of stone .

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What are the

DDx

?

1-

Renal

:

urolithiasis

,

UTI,Pyelonephritis

.

2- G.I :Acute cholecystitis , diverticulitis, colitis3- R.S: Rt Lower lobe pneumonia4- gynecological : ovarian torsion,ovarian cyst, ectopic pregnancy .

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What’s your next step ?

Examination.

Lab Investigations

urine analysis and culture ,CBC, KFT, serum electrolytes

Radiography

CT

abd

-pelvis without contrast, US urinary system , KUB ,IVP

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Why to do urine analysis and culture ?

Should be performed in all patient with suspected calculi.

Microhematuria

, pH,

crystals,bacteria

Uric acid stones – acidic urine

Infection – alkaline urine

Limited

pyuria

is fairly common response to irritation caused by a stone.

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Radiological investigations

1- CT scan without contrast:

The best imaging tool to diagnose any acute flank pain

Sensitivity 95-100% , Specificity 94-96%.

Show

all stone types in all locations except

indinavir

stone

It can give idea about non- urinary causes of the pain.

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2- U.S…….WHY ?

Sensitivty19

%, specificity 97%

Accessible

Good for diagnosis of

hydronephrosis

and renal stones

Poor visualization of

ureteral

stone.

Procedure of choice for patients who should avoid radiation, including pregnant women

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3- KUB:

May

be sufficient to document the

size and location of

radio opaque

urinary calculi

(Ca

oxalate, Ca phosphate

)

Disadvantages:

Will miss radiolucent uric acid stones (10%), small stones, stones with overlying bony structures (unfortunately stones are frequently obscured by stool or bowel gas, ureteral stones overlying the bony pelvis or transverse processes of vertebrae).Opacities on a plain abdominal radiograph that may be confused with renal stones: calcified mesenteric lymph nodes, stones in the appendix , stool and phleboliths ( calcification in walls of vein) .

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4-Intravenous

pyelogram

:

Relatively safe despite the need for

contrast

Appear as filling defect

Provides information about

obstruction

,the

stone

(size, location, radiodensity) and degree of obstruction.Contra-indications : 1- Allergy such as Asthma, Urticaria ( may cause anaphylactic shock ). 2- Renal impairment 3- Pregnancy

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Complications :

hydronephrosis

: Aseptic dilatation due to back pressure .

pyonephrosis

: Septic dilatation – kidney turns into bag of pus

Renal failure

:Bilateral

staghorn

stones may be asymptomatic till presentation with features of renal failure.

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Now … You diagnose her as a case of

ureteric

stone .. Do you admit her ?

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When to admit the patient ?

Infection on top of obstruction

Fever

Intractable pain or vomiting

Solitary kidney or transplanted kidney with obstruction

bilateral stones

VIP persons

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How to treat ?

Lines of treatment :

Conservative

ESWL

JJ stent insertion or

ureteroscopy

PCNL

Open or laparoscopic surgery :

Pyelolithotomy

or Nephrolithotomy

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conservative

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Urgent temporary procedures

Indications:

Significant Obstruction that impair kidney function

Infection

Aim :

Drain urine from the kidney

to relief the obstruction

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Double J stent

A thin, hollow tube placed inside the ureter during surgery to ensure drainage of urine from the kidney into the bladder. J shaped curls are present at both ends to hold the tube in place and prevent migration

*

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Nephrostomy

Tube

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Extracorporeal shock wave lithotripsy (ESWL) :

A urinary calculus has a crystalline structure. When hit with shock waves of sufficient energy it disintegrates into fragments.

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INDICATION:

It is a good option

for

ureteral and renal stones smaller than 2 cm.

Contraindications:

Pregnancy , bleeding disorders, active UTI,

severe skeletal malformations and severe obesity, which prevent targeting of the stone;

arterial aneurysm in the area of the stone

Complication

Hematuria

Incomplete stone fragmentation & obstructionUreteric colic ( NSAID ) “Steinstrasse” ( stone street ) usually due to a large “ Leading fragment”

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2-Ureteroscopy

passes

through urethra and bladder into the ureter.

then move the scope through ureter until it reaches the location of the kidney stone.

we can take out the kidney stone using a small "basket" that comes out of the end of the

ureteroscope

. Small stones can be removed all in one piece. Larger stones may need to be broken up before you can remove

them by laser or

lithoclast

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3-Percutaneous

nephrolithotomy

(PCNL)

The aim is to remove all fragments if possible, and this may take some time if the calculus is large

It might need multiple tracts if occupying two or more calyces

PCNL and open or lap. surgery are equally effective for the management of renal stones.

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Indication

Large (>2 cm in diameter) or complex calculi

Cystine

stones (relatively resistant to shock wave lithotripsy).

Contraindication

All contraindications for general

anaesthesia

apply.

Patients receiving anticoagulant therapy must be monitored carefully pre and postoperatively. Anticoagulant therapy must be discontinued before

PCNLComplications haemorrhage from the punctured renal parenchyma perforation of the collecting system perforation of the colon or pleural cavity during placement of the percutaneous track.

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4-Open surgery

Indication

Treatment failure of ESWL and/or PCNL.

Intrarenal

anatomical abnormalities: (

infundibular

stenosis

, stone in the

calyceal

diverticulum, obstruction of ureteropelvic junction, strictures)Morbid obesitySkeletal deformitiesNon-functioning kidney (Nephrectomy)Patient’s choice; patient may prefer a single procedure and avoid the risk of undergoing multiple PCNLs

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5-flexible

ureteroscopy

It is a device that has a flexible end that is used mainly to search and fragment upper ureteric stone or kidney stone

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Treatment

Treatment depends on

size, location and type of stone

.

Location and size:

>>> Kidney;

1- < 0.5 cm may pass spontaneously we advice patient to increase fluid intake plus pain killers.

2- < 2 cm ESWL or flexible

ureteroscopy

3- > 2 cm by PCNL +/- ESWL

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..

>>> Ureter;

1- <= 5 mm leave it, drinking water, pain killer +/- CCB or alpha blockers “esp. in lower ureter”.

2- > 5 mm ESWL if upper

ureter

,if mid or lower

ureter

ureteroscopy

is

adviced.Type of stone: Uric acid stone: by alkalizing the urine environment by alkalizing agents (e.g potassium citrate or sodium bicarbonate) and dilution of urine by increase fluid intake. -Allopurinol to reduce the frequency of stone with recurrent uric acid stone or gout.

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..

Cystine

stone

;

High fluid intake(4-5 L/day),

alkalanisation

of urine and chelating agents (D-

pincillamine

) to prevent formation of

cystine stone in patients with cystinuria. PCNL for stone if it’s formed. Struvite;PCNL treatment. Antibiotics is the mainstay of therapy to prevent the recurrence ?

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