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UROLITHIASIS.pptx
- 1. UROLITHIASIS PRESENTED BY: MOHAMMAD MASOOM PARWEZ MODERATOR: DR. BHARATI PANDYA
- 2. INTRODUCTION • 3rd most common pathology following UTI and prostate • Prevalence – increasing • Peak age – 4th to 6th decade • M:F - 2:1 • Recurrence rate – as high as 50% in 5 years* • Struvite stones – H.C.G. von Struve (Russian naturalist); previously “guanite” (bat droppings) • Ca oxalate dihydrate – “Weddellite” – resembles sea floor of Weddell sea in Antarctica
- 3. PATHOGENESIS • Physical and chemical properties of urine • Supersaturation of urine with solutes • Depletion of stone inhibitors (citrate, phosphate, magnesium)
- 4. Risk factors • Crystalluria: • Ca oxalate dihydrate: bipyramids • Ca oxalate monohydrate: biconcave oval/ dumbbell • Cystine crystals: hexagonal • Struvite: coffin lids • CaHPO4 brushite stones: splinter like • Ca apatite and uric acid crystals: amorphous powder • Socioeconomic status: • More common in affluent, industrialized countries
- 5. Risk factors • Diet: • High saturated and unsaturated fatty acids • High animal protein and sugar • Less dietary fiber, vegetable protein and unrefined carbs • High dietary sodium • Fluid intake and urine output • Occupation: • Sedentary lifestyles • Climate: • Hot climate- dehydration- more UV light – more vit D3 production
- 6. Risk factors • Family history: • Positive family history: twice likely to have stone • Medication: • Triamterene • Antacids containing silica • Carbonic anhydrase inhibitors • Protease inhibitors • Diseases: • Hyperparathyroidism • Renal tubular acidosis (partial/complete) • Jejuno-ileal bypass • Crohn’s disease, • Intestinal resection • Malabsorptive conditions • Sarcoidosis • Hyperthyroidism
- 7. Risk factors Anatomical abnormalities associated with stone formation: • Tubular ectasia (medullary sponge kidney) • Pelvi-ureteric junction obstruction • Calyceal diverticulum • Calyceal cyst • Ureteral stricture • Vesico-ureteral reflux • Horseshoe kidney • Ureterocele
- 8. Classification • Calcium Stones 70-80% – Ca Phosphate 5-10% – Ca Oxalate/Phosphate 30-45% (Mixed) – Ca Oxalate 20-30% • Struvite stones 15-20% • Cystine stones -3% • Uric acid stone • Xanthine stone
- 10. ETIOLOGY • Poly-crystalline aggregates of crystalloid and organic matrix • Super-saturated urine – depends on urinary pH, ionic strength, solute concentration and complexation • Crystal inhibitors like magnesium, citrate and pyrophosphate inhibits active crystal growth
- 11. THEORIES • Nucleation theory – stones originate from crystals / foreign bodies immersed in supersaturated urine • Crystal inhibitor theory – stones formed due to absence or low concentration of inhibitors
- 12. ETIOLOGY Crystal stones – • Nucleation – • initiates the stone process • induced by proteinaceous matrix, crystals and foreign bodies • heterogenous nucleation requires less energy and may occur in less saturated urine • Crystals of one type serve as a nidus for another crystal with similar lattice, eg: uric acid crystals initiating ca oxalate formation • Growth • Aggregation
- 13. ETIOLOGY • THEORY OF MASS PRECIPITATION: • Suggests that collecting tubules become plugged with crystals – stasis – further stone growth • FIXED PARTICLE THEORY: • Formed crystals are retained within cells or beneath tubular epithelium
- 14. ETIOLOGY • Matrix stones: • non crystalline, matrix component of urinary stones comprises predominantly of protein, with small amounts of hexose and hexosamine • Associated with previous kidney surgery or chronic UTI; gelatinous texture • Histology: laminations with scant calcifications • Radiolucent on x rays • NCCT reveals calcifications • Serves as nidus for crystal aggregation
- 15. STONE VARIETIES • Calcium: • 80-85% of all stones • Causes – elevated urinary calcium, elevated urinary uric acid, elevated urinary oxalate, decreased urinary citrate • Symptoms develop secondary to obstruction with resultant pain, infection, nausea and vomiting • Nephrocalcinosis – calcification of renal parenchyma; frequently found in RTA and hyperparathyroidism Ca Oxalate “mulberry stone”
- 16. STONE VARIETIES Calcium: • Absorptive hypercalciuric nephrolithiasis • Secondary to increased calcium absorption from the small bowel- increased load of calcium filtered from the glomerulus – suppression of PTH – decreased tubular reabsorption of calcium – hypercalciuria (>4mg/kg) • Resorptive hypercalciuric nephrolithiasis • 10% of patients with obvious primary hyperparathyroidism • Commonly seen in women • Hypercalcemia with elevated PTH – diagnostic • Treatment – surgical removal of adenoma
- 17. STONE VARIETIES Calcium: • Renal induced hypercalcemia • Intrinsic renal tubular defect of calcium excretion • Hyperuricosuric calcium nephrolithiasis • Hyperoxalouric calcium nephrolithiasis • Hypocitrate calcium nephrolithiasis
- 18. STONE VARIETIES Struvite: • Composed of Magnesium ammonium phosphate • Commonly in women • Presents as renal staghorn • Infection stones due to urea splitting organisms like Proteus, Klebsiella, Pseudomonas, Staphylococcus and Mycoplasma • Alkaline urinary pH due to high ammonium concentration • m/m: culture specific antibiotics; removal of catheters
- 20. STONE VARIETIES Uric Acid: • <5% of all calculi • Common in men • Patients with gout, myeloproliferative disease, rapid weight loss, cytotoxic drug therapy have increased incidence • Elevated urinary uric acid due to dehydration and excessive purine intake • Acidic urine pH<5.5 • Treatment – hydration, alkalinisation, restricting dietary purines, Allopurinol
- 21. STONE VARIETIES Cystine: • Inborn error of amino acid metabolism including cystine, ornithine, lysine, arginine • Genetic defect chromosome 2p • Classic cystinuria – AR inheritance • 1-2% of all stones • Peak incidence – 2nd or 3rd decade
- 22. STONE VARIETIES • Family history of urinary stones • X-ray – faintly opaque ground glass, smooth edged stone • Amber coloured stones with hexagonal crystals • m/m: high fluid intake, urinary alkalinisation, low methionine diet, penicillamine oral doses
- 23. STONE VARIETIES Xanthine: • Congenital deficiency of xanthine dehydrogenase • Serum uric acid is low, hypoxanthine and xanthine is high • Stones are radiolucent, with tannish yellow color • m/m: high fluid intake, urinary alkalinization
- 24. STONE VARIETIES Indinavir: • Protease inhibitor • Radiolucent stones (6% of patients on drug) • Only stone radiolucent on NCCT • m/m: temporary cessation + iv hydration • Tannish red, falls apart during basket extraction
- 25. STONE VARIETIES Rare: • Silicate: long term antacid use containing silica • Triamterene: radiolucent, antihypertensive containing the drug; discontinue medication
- 26. Clinical features Pain • Renal colic – • stretching of collecting system/ureter • Relatively constant, implies intraluminal origin • Non colicky renal pain: distension of renal capsule • Renal calculi – pain due to local mechanisms (inflammation, edema, hyperperistalsis, mucosal irritation) • Ureter: pain referred to ilio-inguinal and genital branch of genitofemoral nerve • Renal: flank and costovertebral angle
- 28. Clinical features Hematuria • Intermittent gross hematuria / occasional tea coloured urine Infection • Struvite stones common in infection • Calcium phosphate stones Fever • Signs of urosepsis: fever, tachycardia, hypotension, cutaneous vasodilatation Nausea and Vomiting
- 29. Evaluation History • Nature of pain, onset, character, potential radiation • Associated nausea, vomiting, gross hematuria • h/o similar pain • h/o medication • Family history • Diet
- 30. Evaluation Physical examination: • Acute renal colic – severe pain, attempting to find relief in multiple, bizarre positions • Tachycardia, sweating, and nausea • Costovertebral angle tenderness • Abdominal mass – long standing obstructive uropathy
- 31. Investigations
- 32. STONE WORK-UP • To asses renal function and metabolic risk factors for stone formation • Blood tests: • Serum electrolytes and Serum Creatinine • Serum Calcium • Serum Uric acid • Serum Phosphorus • 24 hrs. urine collection for • pH Creatinine • Calcium Phosphorus and • Oxalate Magnesium • Uric acid Sodium • Citrate Total volume • Stone Analysis
- 33. Evaluation Diagnosis : Initial evaluation • Urinalysis • Urine culture • Plain x-ray of KUB. • Renal Ultrasound demonstrates the stone along with any hydronephrosis if present. • Intravenous pyelography • Axial spiral CT confirms the calculus, and demonstrates the exact degree of obstruction.
- 35. Urinalysis • Gross or microscopic hematuria. • Pyuria, may accompany obstruction even in the absence of identifiable infecting organisms. • Severe pyuria is present, infection should be considered (especially in a female), since the stones may be secondary to infection.
- 36. A x ray KUB showing stones in rt kidney
- 37. A USG showing acoustic shadow produced by kidney stone
- 38. Intravenous pyelography • Excretory pyelography – information about function of kidney and location of stone • Contra-indicatons - • allergy to contrast media • S-creatinine level > 200 µmol/L • On medication with metformin
- 39. Non-contrast CT • Advantages: fast and non invasive, gives accurate location of stone • Disadvantages: specificity/sensitivity low for other pathologies (AAA, appendicitis) • Does not evaluate renal function or degree of obstruction
- 40. CT Urography • Advantages: Renal function • Disadvantages: uses Renal contrast media ( allergy, nephrotoxic) • - Normal BUN, Creatinine require before RCM • - Metformin & RCM severe Lactic acidosis, nephrotoxicity • -False negative if stone small, radiolucent, partially obstructing, or passes into bladder before contrast passed by kidneys
- 41. Cystoscopy Cystoscopy shows swelling of the ureter orifice in lower location of the stone, it may also partially project out to the orifice.
- 42. STONES OF THE URINARY TRACT • Treatment : • Depends on size, location, degree of obstruction and patients clinical status • Patients with infection or high grade obstruction require prompt intervention in the form of retrograde ureteral catheter or percutaneous nephrostomy drainage • About 90% of ureteral calculi measuring less than 4 mm pass spontaneously whereas only 20% of calculi measuring more than 6 mm pass • Expectant treatment is indicated in asymptomatic, non obstructed, non infective with stone size less than 4 mm diameter in the lower third of ureter
- 43. STONES OF THE URINARY TRACT • Drink copious amount of water, four to six weeks duration is allowed for passage of stone • Stone extraction is indicated for uretral stones that do not pass spontaneously • Small stones may be grasped directly or engaged in stone basket and extracted • Larger stones may be fragmented using • ultrasound • electrohydraulic • pneumatic • laser lithotripsy
- 44. STONES OF THE URINARY TRACT • Shock wave lithotripsy : ureteral stones less than 8 mm diameter • it may be performed with or without a stent as long as stone can be adequately visualised • Ureterolithotomy is rarely needed given the high success rate of non- operative and minimally invasive technique like SWL, ureteroscopy and laparoscopy
- 45. Pain relief during acute colic- • Pain relief involves the administration by various routes of the following agents: • Diclofenac sodium • Drotaverine • Hydromorphone hydrochloride + atropine sulphate • Tramadol • OTHER MEDICATIONS- • Tamsulosin increases peristalsis of ureter • Phosphodiesterase inhibitors- Dutasteride
- 46. Pain relief • Not responding to analgesics: drainage by stenting or percutaneous nephrostomy (PN) or stone removal should be carried out
- 47. Management • Average time to pass stone varies (7-20 days) • Long acting CCB (Nifedipine) and steroids may enhance passage • F/U Urology in 7 days • Stone saved/submitted to urologist for analysis. • Return immediately if intractable, severe pain, persistent nausea and vomiting, fever and chills
- 48. Indications for Admission • Obstruction with infection • Persistent pain • Persistent nausea and vomiting • Urinary extravasation • Hypercalcemic crisis
- 49. Indications of surgery • Frequent attacks of the renal colic or persistent pain that disables the patient • Obstruction - hydronephrotic degeneration of the kidney • Obstructive anuria • Frequent attacks of the acute pyelonephritis • Gross hematuria • Calculous pyonephrosis • Stone in the ureter of the sole kidney that won’t pass away spontaneously
- 50. 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 • 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
- 51. ESWL
- 52. Steinstrasse (Stone street) - post ESWL
- 53. ENDOSCOPIC PROCEDURES • Cystoscopic technique stones in the distal ureter and bladder can sometimes be removed with a wire stone basket.Removal of bladder stones termed as cystolitholapexy • Ureteropyeloscopy With this technique, small stones can be easily trapped in a stone basket and safely extracted through the dilated ureter
- 54. Percutaneous nephrostomy • This technique, along with refinements in endoscopic instruments and advances in fiberoptics, allows endoscopic manipulation in the upper urinary tract by the percutaneous approach Laparoscopic procedures • Pyelolithotomy done for pelvic stones and lap ureterolithotomy done for mid ureteral stones
- 55. Open Surgical Procedures • Pyelolithotomy: Simple pyelolithotomy is used for removal of calculi confined to the renal pelvis - This procedure is not indicated for the removal of entrapped caliceal stones or large, branched renal calculi
- 56. Open Surgical Procedures • Ureterolithotomy- -There are retroperitoneal, transperitoneal and combined surgical accesses. It depends on stone location
- 58. Complications • Ureteral scarring and stenosis • Nidus for infection • Serious infection of the kidney that diminishes renal function • Urinary fistula formation • Ureteral perforation • Extravasation • Urinary outflow obstruction • Hydronephrosis • CRF
- 59. Summary
- 61. Summary
- 63. Summary
- 64. PREVENTION
- 68. REFERENCES • Sabiston Textbook of Surgery , 20th edition • Smith and Tanagho’s General Urology , 18th edition • Guidelines on Urolithiasis – European association of Urology, 2015
- 69. Thank You
Editor's Notes
- #3: 5% risk in 1994, 9% risk in 2010 * - without follow up and medical intervention
- #6: Avg urine output in stone formers: 1.6L/day
- #11: pH – acidic in morning, alkaline after meals Ionic strength – concentration of monovalent ions Solute concentration – above solubility product-metastable urine leading to crystal formation and heterogenous nucleation Complexation - Tendency to form complexes with ions
- #12: Nucleation – in 1/3rd patients, 24hr urine collection is completely normal Crystal inhibitor – some people have abundance of inhibitors with stones, some have no inhibitors and still have no stones
- #16: Renal tubular acidosis
- #27: Stone burden does not correlate with severity of symptoms