UROLITHIASIS

DEFINITION
Urolithiasis (from Greek oron-urine and
lithos-stone) is the condition where urinary
stones are formed or located anywhere in
the urinary system.
 BACKGROUND
Predominance in men approx. 3:1
Peak incidence between fourth and fifth decade of life.
Renal colic affects approximately 1.2 million people each
year in USA and accounts for approximately 1% of all
hospital admissions
A lifetime risk:
2-5% for Asia
8-15% for the West
 RISK FACTORS
Start of disease early in life: <25 years
Stone containing brushite (phosphate mineral)
Only one functioning kidney
Disease associated with stone formation:
Hyperparathyroidism
Renal tubular acidosis (partial/complete)
Jejunoileal bypass
Crohns disease
Intestinal resection
Malabsorptive conditions
Sarcoidosis
Hyperthyroidism
 RISK FACTORS
Medication associated with stone formation:
Calcium supplements
Vitamin D supplements
Acetazolamide - ascorbic acid in megadoses ( > 4 g/day)
Sulphonamides - triamterene
Indinavir
Anatomical abnormalities associated with stone formation:
Tubular ectasia (medullary sponge kidney)
Pelvo-ureteral junction obstruction
Calix diverticulum, calix cyst
Ureteral stricture
Vesico-ureteral reflux
Horseshoe kidney
Ureterocele
 Etiology (according Capital and I. Pogo Elko).
Disorders of urinary tract: Metabolism disorders.
Congenital abnormalities
Obstructive processes
Neurogenic duskiness of the urinary
tract
Inflammative and parasitogenic
damages
Foreign bodies of urinary tract
Traumatic injuries
Liver and digestive tract disorders
Latent and manifested hepathopathiy
Hepatogenic gastritis
Colitis
Endocrine diseases
Hyperparathyreoidism
Hyperthyroidism
Hypopituitaric diseases
Infect focuses of the urogenital
system.
Essential hypercalciuria
Renal rickets
Injuries those leads to continuous
immobilization
Fractures of the vertebral column and
limbs
Osteomyelitis
Diseases of the bones and joints
Chronic diseases of the visceral organs
and nervous system.
Climate and geographical causes.
Dry and hot climate with a high
vaporization
Decrease water supply
Iodine deficiency
Disorders of nutrition and vitamins
balance:
Retinole and oscorbine acid deficiency
Excessive amount of the
ergocalciferole
 Theories of Stone Formation
Nucleation Theory
Stone Matrix Theory
Inhibitor of Crystallization
Theory
 Chemical Types
Four main chemical types:
u Calcium stones (Account for 75% )
u Struvite (magnesium ammonium phosphate) stones
u Uric acid stones
u Cystine stones
 Clinical Manifestations

Acute obstruction
Renal colic
Severe Accompanied
nausea and vomiting
Due to celiac ganglion
stimulation.
Onset is sudden
often during the night or
in the early morning
 Clinical Manifestations
Fever urinary tract infection
HR and BP elevated pain and agitation
caused by the renal colic.
Abdomen flat and soft, with moderate
deep tenderness on palpation
Extensive hyperesthesia
Costo-vertebral area may be tender to
percussion.
 Clinical Manifestations
Upper urinary tract
Extreme crescendo like pain in the flank that generally
radiates laterally around the abdomen, and also:
Groin and testicles males,
Labia major females.
Midureter
Pain tends to radiate to the lateral flank and
abdominal region
Distal ureter (near the ureterovesical junction)
Symptoms of bladder irritation (frequency and
urgency or genital pain).
 Laboratry Investigations
Stone analysis: In every patient one stone
should be analysed

Blood analysis: Calcium Albumin Creatinine

Urate
Urinalysis: Fasting morning spot urine
sample
Dip-stick test: pH, Leucocytes/
Bacteria, Cystine test, Ca, P,
citrate, urate
 Urinalysis.
Gross or microscopic
hematuria.
May be absent in complete
obstruction
Microhematuria may be
present in symptomatic partial
obstruction
Pyuria
Moderate, accompany
obstruction even in the
absence of identifiable
infecting organisms
Severe, infection should be
considered (especially in a
female)
 Diagnostic imaging

Routine examination involves a plain abdominal film of the

kidneys, ureters and bladder (KUB) At least 90% of all
renal stones are radiopaque and therefore readily visible
on a plain film of the abdomen
 Diagnostic imaging

Excretory pyelography
contraindication:
Allergy to contrast media
S-creatinine level > 200
mol/L
Medication metformin
Myelomatosis
 Diagnostic imaging

Special examinations that

can be carried out include:
Retrograde or antegrade
pyelography
Retrograde pneumo-
pyelography or cystography
Spiral (helical) unenhanced
computed tomography (CT)
Scintigraphy.
 Diagnostic imaging

Ultrasonography indication:
Patients in whom it is not
possible to obtain an
intravenous urogram
Pregnant women
Anuric patients
Chronic renal failure
Hydronephrosis

Acoustic shadowing may be

diagnostic.
 Diagnostic imaging

Cystoscopia shows swellowing of the ureter

orifice in lower location of the stone, it may also
partially project out to the orifice.
Cystoscopy
TREATMENT
Conservative
Instrumental
Surgical
 Pain relief
Pain relief involves the administration
by various routes of the following
agents:
Diclofenac sodium
Indomethacin
Tramadol
 Pain relief
Warm bath
Spasmolytic cocktails (with papaverine,
spasmalgone, no-spanum, promedole) should be
taken.
A high dosage of the cystenal or urolesan (20 drops
on the piece of sugar) is rather effective at the start
of the renal colic.
 Pain relief
diclofenac sodium, 50
mg administered
twice daily over 3-10
days
 Pain relief
When pain relief
cannot be obtained
by medical means,
drainage by stenting
or percutaneous
nephrostomy (PN) or
stone removal
should be carried
out.
 Stone removal
The size, site and shape of the stone at the initial
presentation influence the decision to remove the
stone.
Spontaneous stone passage can be expected in up
to 80% of patients with stones not larger than 4
mm in diameter. For stones with a diameter
exceeding 7 mm the chance of spontaneous
passage is very low.
The overall passage rate of ureteral stones is:
Proximal ureteral stones: 25%
Mid-ureteral stones: 45%
Distal ureteral stones: 70%
 Indications for Active Stone removal
Stone removal is usually
indicated for stones with a
diameter exceeding 6-7 mm.
Active stone removal is strongly
recommended in patients fulfilling
the following criteria:
Persistent pain despite adequate
medication
Persistent obstruction with risk of
impaired renal function
Stone with urinary tract infection
Risk of pyonephrosis or urosepsis
Bilateral obstruction.
Obstructing calculus in a solitary
functioning kidney
 Stone removal
A test for bacteriuria
Screening with dipsticks
urine culture
treatment with antibiotics should be started
before the stone-removing procedure.
Bleeding disorders and anticoagulation treatment
should be considered.
 Indications to surgical operation

Frequent attacks of the renal colic or persistent pain that

disables the patient.
Disorder of the urine outflow causing the hydronephrotic
degeneration of the kidney.
Obstructive anuria.
Frequent attacks of the acute pyelonephritis, progress of
the chronic pyelonephritis that causes renal insufficiency.
Total hematuria.
Calculous pyonephrosis, apostematous pyelonephritis or
carbuncle of the kidney.
Stone at the sole kidney that causes obstruction.
Stone in the ureter of the sole kidney that wont pass
away spontaneously.
 Stone removal
In patients with coagulation
disorders,pregnant the following
treatments are contra-indicated:
extracorporeal shock wave
lithotripsy (ESWL),
percutaneous nephrolithotomy
with or without lithotripsy (PNL),
ureteroscopy (URS) and open
surgery.

In such women, the preferred

treatment is drainage, either with
a percutanous nephrostomy
catheter, a double - J stent or a
ureteral catheter .
 Percutaneous Procedures
Percutaneous nephrostomy.
without using the
standard large flank
incisions and
mobilization of the
kidney.
This technique, along with
refinements in endoscopic
instruments and advances
in fiberoptics, allows
endoscopic manipulation in
the upper urinary tract by
the percutaneous
approach.
Percutaneous
nephrolithotomy with or
without lithotripsy (PNL)
 Closed Surgical Procedures
Cystoscopic technique
[With the patient under anesthesia
and with fluoroscopic control,
stones in the distal ureter can
sometimes be removed with a
wire stone basket]
Ureteropyeloscopy
[Manipulation of small ureteral
stones under direct vision with a
ureteroscope is a major advance
in the management of ureteral
calculi. With this technique, small
stones can be easily trapped in a
stone basket and safely extracted
through the dilated ureter.
 Extracorporeal Shock Wave Lithotripsy
An extracorporeal noninvasive
technique that uses shock waves
to disintegrate urinary calculi while
the patient is immersed in a water
bath has been tested extensively
and is now in clinical use. With
this technique, calculi in the upper
urinary tract are reduced to
fragments, which pass
spontaneously from the collecting
system and bladder in most
patients.

Size, location, and consistency of

stone determine the number of
shocks needed for fragmentation.
In general, between 500 and
2,000 shocks arc necessary to
fragment and pulverize an
intrarenal calculus sufficiently for
complete passage.
 Open Surgical Procedures
Pyelolithotomy: Simple
pyelolithotomy is used for
removal of calculi
confined to the renal
pelvis. Minimal dissection
of the renal sinus is
usually needed, and
exposure of the entire
kidney is not re-quired.
This procedure is not
indicated for the removal
of entrapped caliceal
stones or large, branched
renal calculi.
 Open Surgical Procedures
Ureterolithotomy. There are
retroperitoneal, transperitoneal
and combined surgical accesses
It depends on stone location.
To remove stone from the superior
ureter the Fedorovs access is
used, f
from medial ureter Cuckulidzes
or Derevyanko access is
performed
the inferior ureter Pyrogovs
access is needed, the pelvic
portion of ureter may be accessed
through the suprapubic arcuate
incision.
 Open Surgical Procedures

Nephrectomy Nephrolithotomy Cystolithotomy

 Preventive treatment in calcium stone
disease
For a normal adult, the 24-h urine volume should
exceed 2000 ml
 Preventive treatment in calcium stone
disease
Diet should be of a 'common sense' type - a mixed
balanced diet with contributions from all food groups
but without excesses of any kind.
The intake of fruits and vegetables should be
encouraged because of the beneficial effects of fibre.
Care must be taken, however, to avoid fruits and
vegetables that are rich in oxalate. The following
products have a high content of oxalate :
Rhubarb 530 mg oxalate/100 g
Spinach 570 mg oxalate/100 g
Cocoa 625 mg oxalate/100 g
Tea leaves 375-1450 mg oxalate/100 g
Nuts 200-600 mg oxalate/100 g.
 Preventive treatment in calcium stone
disease
Vitamin C in doses up to 4 g/day can be taken
without increasing the risk of stone formation.
Animal protein should not be ingested in excessive
amounts. It is recommended that the animal
protein intake is limited to approximately 150 g/
day.
Calcium intake should not be restricted unless there
are very strong reasons for such advice. The
minimum daily requirement for calcium is 800 mg
and the general recommendation is 1000 mg/day.
 Preventive treatment in calcium stone
disease
The intake of foodstuffs particularly rich in urate
should be restricted in patients with
hyperuricosuric calcium oxalate stone disease , as
well as in patients with uric acid stone disease.
The intake of urate should not be more than 500
mg/day.
Below are examples of food rich in urate :
Calf thymus 900 mg urate/100 g
Liver 260-360 mg urate/100 g
Kidneys 210-255 mg urate/100 g
Poultry skin 300 mg urate/100 g
Herring with skin, sardines, anchovies, sprats
260-500 mg urate/100 g.
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ATTENTION