UROLOGY

1. DISCUSS THE
MANAGEMENT
OF URINARY
CALCULUS
DR BASHIR YUNUS
SURGERY DEPARTMENT A.K.T.H
22/4/14
4/21/2014 1

2. OUTLINE
INTRODUCTION
o ANATOMY
o EPIDEMIOLOGY
o RISK FACTOR
o TYPES
o AETIOPATHOGENESIS
PRESENTATION
o EMERGENCY
o ELECTIVE
o ASYMPTOMATIC
MANAGEMENT
o RESUSITATION
o HISTORY
o EXAMINATION
o DIFFERENTIALS
o INVESTIGATION
o TREATMENT
FOLLOW-UP
PREVENTION
PROGNOSIS
STONES IN SPECIAL SITUATIONS
FUTURE TRENDS
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3. INTRODUCTION
• Urinary calculus or stone along the urinary tract.
The 3rd most common urological disease preceded
only by UTI and prostate pathology.
• Stone can be found anywhere along the
genitourinary system, of various sizes with varying
presentations.
• Management of stones have been revolutionized
by advancement in technology and it depends on
the availability of equipment and expertise.
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4. ANATOMY
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5. ANATOMY
• Anatomical narrowings:
 Ureteropelvic junction
 Crossing of the iliac
artery
 Juxtaposition of broad
ligament or vas
deference
 Entering the bladder
wall
 Ureteric orifice
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6. EPIDEMIOLOGY
• World wide distribution, commoner in developed
countries also increasing developing countries.
• Western Europe -2-3% of population
• Nigeria incidence 7-34 per 100,000.
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7. Nigeria
• Mshelia, 2005. Maiduguri, M:F 12:1 76.9% calcium
stones
• Ekwere, Calabar, high hospital incidence, 19.1 per
100,000. Attributed high sea food consumption.
• Hassan, Zaria, Paediatric population 9.6 per 100,000.
59% congenital anomalies
• Mbonu, Enugu, M:F 5:1 13 per 100,000 hospital
population 80% due to obstruction.
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8. NIGERIA
• S A AJI, S U ALHASSAN, A M MOHAMMAD, SA
MASHI. KANO; 2011
• M:F 3:1
• Peaks at 3rd decade
• Predominantly upper tract
• Loin pain as the commonest symptoms 34.2%
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9. RISK FACTORS
• FAMILY HISTORY: 25% of patient with recurrent calcium
calculi have family history
• DEHYDRATION: increase concentration and reduced
solubility of urine constituent. Decrease fluid
Intake, increase loss of fluid, hot arid region
• CLIMATE: hot climate.
• SEX: commoner in males. Testosterone increase
endogenous oxalate production and oxaluria.
oestrogen increase urinary citrate conc. Thereby
preventing oxalate crystal deposition.
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10. RISK FACTORS
• DIET: excessive intake of food containing
purines, oxalate, calcium phosphate.
• AFFLUENCE
• STRESS
• OCCUPATION: physicians and other white- collar
workers, Catheters.
• HARD WATER
• MEDICATIONS- antihypertensive medication triamterene
• CHANGES IN URINE PH; alkali- (ca, p), acid- (uric
a, cystine)
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11. AETIOLOGY
• METABOLIC CAUSES
 hypercalcaemia
o Primary hyperparathyroidism
o Prolong immobilization
o Vitamin D intoxication
o Milk alkali syndrome
o Sarcoidosis
o Ectopic parathyroid hormone secretion –
hypernephroma, bronchogenic ca.
 Enzyme disorders
o Xanthinuria
o Primary hyperoxaluria
 Renal tubular syndromes
o Cystinuria
o Renal tubular acidosis
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12. AETIOLOGY
• METABOLIC
 Hyperuricaemia
o Idiopathic uric acid lithiasis
o Gout
o Myeloproliferative disorders
o Low urinary output states
o Protein catabolism
• Leukemia
• Cytotoxic chemotherapy
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13. AETIOLOGY
• NON-METABOLIC
 Obstruction – stasis, infection, stone formation.
 Infection- urea splitting organisms; E coli, proteus, klebsella, Pseudomonas
 Congenital anomalies ; medullary sponge kidneys, horseshoe kidney
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14. PATHOGENESIS
• Explained by theories
 NUCLEATION THEORY
It state that stone originate from crystals or foreign body
immersed in supersaturated urine.
 MATRIX THEORY
It postulate that matrix may act as a nidus for crystal
aggregation or as a natural glue to adhere small crystals.
 CRYSTAL INHIBITION THEORY
It claims that calculi form owing to the absence or low
concentration of urinary stone inhibitors.
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15. PATHOGENESIS
INHIBITORS OF CRYSTALLIZATION
• Magnesium
• Citrate
• Pyrophosphate
• Orthophosphates
• Nephrocalcin
• Glycosaminoglycans
• Mucopolysaccharides
• Uropontin
• Urinary peptides
• Artificial urolithiasis inhibitors
• Methylene blue
• Phosphonate ions
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16. THEORIES
• Fix particle theory
o Randalls plaque -- renal papilla
o Carr microliths -- lymphatics
• Theory of mass precipitation
• intranephronic precipitation
• Crystallization Precipitation theory
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17. TYPES
 CALCIUM OXALATE 60%
 PHOSPHATE STONE 30% -forms staghorn cal.
o CALCIUM PHOSPHATE
o AMMONIUM MAGNESIUM PHOSPHATE
o CALCIUM AMMONIUM MAGNESIUM PHOSPHATE(triple phosph)
 URIC ACID AND URATE STONES 5-10%
o More found in bladder than kidneys
o Related to high standard diet
 CYSTINE STONE 1-3%
o May aggregate to form staghorn, recurrence is common
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18. TYPES
• OTHERS
o XANTHENE – def. of xanthene oxidase
o INDINAVIR – ARV drug related
o SILICATE
o MATRIX
o TRIAMTERENE STONES
All are radiolucent
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19. CLINICAL
PRESENTATION
The clinical presentation of patient with urinary calculi
depend mainly on the
o site of stone
o size of the stones,
o unilateral or bilateral stone diseases,
o presence or absence of associated infection
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20. PRESENTATION
EMERGENCY
ELECTIVE
SILENT OR ASYMPTOMATIC
COMPLICATIONS
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21. EMERGENCY
o RENAL COLIC
o It is a sudden acute, intense, agonizing, paroxysmal pain
which begins in the renal angle, then radiates around the
flank towards the bladder, testis in the male or labium
majus in the female, or to the anterior or lateral aspects of
the thigh. (T12-L2)
o Patient rolls around as excruciating sharp pain
superimposed upon a background of continuous
discomfort (peristalsis pushing stone down).
o It is often associated with shock, sweating and nausea or
vomiting.
o It may last only a few seconds or persist for up t0 48h.
o It ends dramatically when the SlOne falls back into
o the pelvis or into the bladder
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22. EMERGENCY
o ACUTE URINE RETENTION
o UROSEPSIS
o CALCULUS ANURIA-
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23. ELECTIVE
• PAIN : a dull or boring, ache in the loin, especially in
the costo-vertebral (renal) angle, due to some
obstruction of the pelvis.
• HAEMATURIA ; usu after strenuous activity
• FREQUENCY
• PASSAGE OF STONE IN URINE
• NON- SPECIFIC ; NAUSEA, VOMITING
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24. ASYMTOMATIC
• They are discovered incidentally during routine
investigations such as urinalysis and imaging for
other disorders
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25. COMPLICATIONS
• RENAL MASS
o secondary hydronephrosis
o squamous cell ca. – prolong irritation
o Pyeonephrosis
o Perinephric abscess
o Renal abscess
o Xantho granulomatous pyelonephritis
• CHRONIC RENAL FAILURE
• PERIURETHRAL ABSCESS/FISTULAE
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26. DIFFERENTIALS
• Non urological
o Appendicitis
o Diverticulitis
o Ectopic pregnancy,salphingitis,tortion of ovarian cyst
o RupturedAAA
o biliary colic
• Urological
o Pyelonephritis
o Stricture,tumour,renal infarction
o Testicular tortion
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27. MANAGEMENT
• Depends on the mode of presentation
• For emergency, patient is resusitated along side
some investigation, before a definative procedure
• Detail history, examination, and investigation are
required for elective or asymtomatic presentation
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28. RESUSITATION
ACUTE RENAL COLIC
• PAIN –
o ANALGESIC- NSAID OR NARCOTICS
• Diclofenac 100mg 2doses usu suffice in acte attack
• +/- antiemetic
OR
• Im pethidine 75mg + antiemetic or morphine
• FLUID
o Given iv, >3L/day if accompanied with vomiting Otherwise liberal fluid
intake
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29. RESUSITATION
• ACUTE URINE RETENTION
o Small stones near the external meatus can be grasped with a grasper.
o Stone in the prostetic urethra
• Instill 2% lidocain jelly(allow for 5min) then push stone into the bladder
using urethral catheter subsequent removed endoscopically
o Stone in the penile urethra
• External urethrotomy
o Stone impacted in a fossa navicularis or external meatus
• meatotomy
• UROSEPSIS
o IV Fluid resusitation for correction of hypotension if present
o iv antibiotics
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30. RESUSITATION
• When acute episode subsides,
o Plain abdominal xray – 90% of stone
o Abdominal USS – 10% stone, infected hydronephrosis, solitary obstructed
kidney
o Urine: Urinalysis, urine microscopy; microscopic haematuria 90%, wbc , ph,
o Urgent U/E Cr- calculus anuria.
• Patient may require nephrostomy for temporal
diversion or relieve of obstruction
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31. RESUSITATION
• INDICATIONS FOR URGENT INTERVENTION
o WHEN THERE IS STONE OBSTRUCTION ASSOCIATED WITH
INFECTION.
o DECREASE RENAL FUCTION
o CACULUS ANURIA- BILATRAL OBSTRUCTION, OBSTRUCTED
SOLITARY KIDNEY
o PYEONEPHROSIS
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32. ELECTIVE
• DETAIL HISTORY
o Risk factors
o Aetiology
o Complications
• PHYSICAL EXAMINATION
o May not reveal any significant finding
o Hydronephrosis as renal angle mass
o Tenderness; lumber or iliac
o A large vesical stone may be felt on bimanual examination
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33. INVESTIGATIONS
• DIAGNOSTIC
o PLAIN X-RAY KUB- 90% of stones
o ABD USS- 10% radiolucent (uric, xanthene)
o IVU- Degree of obstruction
o Degree of function
o Confirms radio- opaque stones
o Show non opaque stones as filling defect
o Number of the kidneys
o Where available, non contrast helical CT scan- gold standard
• AETIOLOGY
o Urinalysis-pH, rbc, microscopy- crystal sediments
o STONE ANALYSIS – for stone passed
o 24 hr urinary calcium (2.5-7.5mmol/24hrs)or uric acid 1g/, cystine 30-
50mg/, oxalate 40mg/
o Nitroprusside test: Urinary cystine concentration rarely exceeds 70mg %.
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34. • BLOOD CHEMISTRY
• RETROGRAGED PYELOGRAM
o is indicated if the kidney is nonfunctioning from acute obstruction
• X-RAY OF SMALL BONES OF THE HAND
o is taken if hyperparathyroidism is suspected when subperiosteal resorption
and cystic areas may be seen
• CYSTOSCOPY
o It is necessary for the evaluation of lowcr urinary tract obstruction c.g.
prostatic hypertrophy, bladdcr infection and visualization of non-opaque
stonc.c;e.g. uric acid stone.
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35. TREATMENT
• OPTIONS
o CONSERVATIVE
o SURGICAL
o URETEROSCOPY
o PCNL
o ESWL
• INTERVENTION DEPENDS ON;
o SIZE OF STONE
o SITE OF STONE
o AVAILABILITY OF TREATMENT
o ABNORMAL ANATOMY OF THE URINARY TRACT
o PATIENT CHIOCE
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36. CONSERVATIVE
• Small stones(<5 mm)
• If stone size
o <4mm 80%pass spontaneously
o 4-6mm 50%pass spontaneously
o >6mm only 10%pass spontaneously
• More distal the better
• Pain controlled
• Absence of renal failure and sepsis
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37. CONSERVATIVE
Conservative measures include:
• 1- Encourage fluid intake ≥ than 3L/day.
• 2- Analgesia (whether NSAID or centrally acting
analgesia).
• 3- Encourage exercise and movement.
• 4-↓ salts intake.
• 5- Alkalanization of urine.
Review and ensure stone has passed
Absence of pain does not confirm stone expulsion
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38. CONSERVATIVE
Indications for intervention:
• Failure of conservative treatment
Intractable pain
refractory vomiting or
refractory haematuria.
• Obstructing large size stone that affecting the renal
function or renal parenchyma. OR Prolonged obstruction
• Non-progressing calculus(impacted)> 2months
• Infection
• Stones >5mm
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39. OPEN SURGERY
• Treat UTI if present before surgery
• X-ray just before surgery to see position of stone.
Surgery is indicated:
o For obstruction with impaired renal function
o Obstruction with infection
o Stone >1cm
o Stone <1cm with symptoms e.g severe pains, haematuria
o Starghorn calculi
o Solitary kidney
o Bilateral obstruction
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40. OPEN SURGERY
• PRINCIPLES
o To preserve as much as possible of the functioning renal tissue
and to prevent complications.
o Anacsthcsia (by induction, halothane) may lead to decreased
urine output after renal surgery in an severly dehydrated patient.
Thus there is no place for hypatcnsive anaesthesia in renal
surgery.
• Special considerations
o In bilateral kidney stone. operate on the most painful side first
then on the other side.
o In bilateral kidney stones with one non-functioning (bad)
kidney, operate on the healthy side first then perform
nephrectomy on the bad kidney.
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41. OPEN SURGERY.
(a) Pyelolithotomy: The renal pelvis is incised and the
stone removed from the pelvis or calyx.
(b) Nephrolithotomy: An incision is made into the
kidney substance to remove large stones.Hemorrhage
is often severe.
(c) Partial or total nephrectomy is required for a
severely damaged kidney.
(d) Ureterolithotomy: An incision is made in the ureter
after it has been exposed and the stone removed
through it.
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42. APPROACHES TO THE
KIDNEY
• Lumbar or simple flank incision.
• Nagamatsu incision.
• Thoracoabdominal incision.
• Transperitoneal and retroperitoneal incisions.
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43. OPEN SURGERY
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44. 4/21/2014 44

45. EXTRA CORPORIAL
SHOCK WAVES (ESWL):
treatment of choice for those patients with
o renal or upper ureteric stones,
o size(10-25 mm) and
o those with failed conservative treatment.
There are 2 types of shock waves emitters:
o supersonic emitters and
o fine amplitude emitters.
Contra indications to ESWL:
• 1. Pregnancy.
• 2. Large abdominal aneurysm.
• 3. Uncorrectable bleeding disorders
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50. ESWL
• Most stone fragments pass within 2-weeks period.
• A 3-month follow-up KUB film helps direct the need
for additional therapy.
• Complications
o Sepsis
o Hematuria
o Transient renal dysfunction
o obstruction
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51. PERCUTANEOUS
NEPHROLITHOTOMY(PCNL):
Antegrade instrumentation of the upper urinary tract
via percutaneous puncture.
indications :
• 1. Big renal stones (≥ 25 mm) –too large for ESWL
• 2. Distal obstruction not cause by the stone: as PUJ
obstruction.
• 3. Stone in calyceal diverticulum.
• 4. Lower pole renal stones where the success of
ESWL is low.
• 5. when there is contra indication for ESWL.
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52. Procedure of P.C.N.L:-
• 1 Anesthesia, - GA,LA,ED
cystoscopy
ureteral catheter
instillation of radiopaque dye to opacify the
renal pelvicaliceal system(p.c.s).
• 2 The patient should be placed in prone position .
• 3- Under uss guide,
the puncture site : few centimeters inferior and
medial to the tip of the 12th rib until it reaches
the renal pelvis and guide wire left in place.
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53. PCNL
• 4-Dalitation of the tract done with metal or plastic
daliators and nephroscopy sheath passed.
• 5-Destruction of renal stones done with various
lithotripters and removal of the fragments through
nephroscopy tract.
• Advantages:
•Stone removal rates between 95-99
(difficult access/complete staghorn 80-85%)
•Short hospitalisation(1-3days)
•Minimal disability
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54. PCNL
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55. PCNL
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56. 4/21/2014 56

57. PCNL
Various types of lithotripters can be used for
destruction and removal of renal stones as
• electrohydrolic,
• ultrasonic
• laser probes lithotripters
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58. URETEROSCOPY :
Mainly for treatment of ureteric stones especially in the
fallowing situations
o 1- Mid and lower ureteric stones with
failure of conservative expectant treatment
where ESWL is contraindicated.
o 2- Upper ureteric stones with
failure of conservative and ESWL treatment.
o 3- Impacted upper ureteric stones where ESWL is
contra indicated.
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59. URETEROSCOPE
• A small endoscope, which may be
rigid, semirigid, or flexible, is passed into the bladder
and up the ureter to directly visualize the stone.
• directly extracted using a basket or grasper or
broken into small pieces using various lithotrites
(eg, laser, ultrasonic, electrohydraulic, ballistic).
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63. Dormia basket
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64. TREATMENT OPTIONS
FOR BLADDER CALCULI
1.Endoscopic vesico litholapaxy :
• Cystolitholapaxy allows most stones to be broken and
subsequently removed through a cystoscope.
• By cystoscope with use of various types of lithotripters as
mechanical, ultrasonic, electrohydrolic or laser
lithotripters.
2. Open vesicolithotomy :
• It is mainly used for very large vesical stones and in
children where transurtheral surgery carry high risk of
uretheral stricture.
• It also indicated where facilities for endoscopic surgery
are not present.
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65. PREVENTION
General measures
o Hydration: aim at urine output >2L/24hrs
o Dietary restriction
• Decrease protein intake
• Decrease dietary calcium
• Decrease sodium intake
• Decrease oxalate intake
• Avoid excess vitamin c
• Decrease phosphate
Increase dietary fibre
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66. PREVENTION
Specific measures
o Thiazide diuretics i.e. for calcium oxalate stones
o Orthophosphates
o Sodium cellulose phosphates: this tends to bind
to calcium thereby inhibiting the intestinal
absorption of calcium
o Allopurinol:→ decreases the production of uric
acid.
o Citrates e.g. sodium potassium citrate, potassium
citrate.
o Magnesium
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67. FOLLOW UP
• History – symptoms
• Physical examination
• Metabolic analysis
• Assessment of renal function – U/ECr, USS
• Ensure preventive measures
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68. PROGNOSIS
• Renal calculi may recur especially if preventive
measures are not rigorously pursued.
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69. STONES IN SPECIAL
SITUATION
RENAL TRANSPLANTATION
• Urinary stones are rare.
• Classic renal colic absent (Perirenal nerves are
severed at the time of renal harvesting )
• Presumptive diagnosis of graft rejection –high index
of suspicion
• With radiographic and ultrasonic evaluation is the
correct diagnosis made
• Treatment;
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70. PREGNANCY
• Renal colic is the most common nonobstetric cause of acute
abdominal pain during pregnancy
• Calculi are relatively rare, with an incidence 1:1500 pregnancies.
• Caution is taken regarding radiation exposure (especially in the 1st
trimester), medications, anesthesia, and surgical intervention.
• About 90% of symptomatic calculi present during the 2nd and 3rd
trimesters.
• Investigations; renal uss and limited abdominal x-rays with
appropriate shielding.
• Treatment ;Temporal- double-J ureteral stent or a percutaneous
nephrostomy tube under local anesthesia.
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71. STONES IN SPECIAL
SITUATION
• OBESITY
Obesity is a risk factor for the development of urinary
calculi.
• Surgical bypass procedures can cause hyperoxaluria.
• Problems: limitation in physical examination, diagnostic
and treatment options, misguide incisions, prone
positioning on lithotripters
• Ultrasound examination is hindered by the attenuation of
ultrasound beams.
• CT, fluoroscopy tables, and lithotripters all have weight
limitations
• Treatment : open surgery
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72. STONES IN SPECIAL
SITUATION
PEDIATRIC PATIENTS
• Urinary calculi are unusual in children.
• Children born prematurely and given furosemide while in the
neonatal ICU are at increased risk of developing urinary stone
disease.
• Possibilties of genitourinay abnormalities or inherited genetic
disorder such as cystinuria, distal renal tubular acidosis, or
primary hyperoxaluria.
• A full and thorough metabolic evaluation should be
undertaken. Stone analysis is particularly helpful in directing
these investigations.
• Treatment may be limited by endoscope size. Preliminary
data show no change in renal growth after ESWL.
• PCNL has become an established treatment.
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73. STONES IN SPECIAL
SITUATION
• DYSMORPHIA Severe skeletal dysmorphia
• Congenital (spina
bifida, myelomeningocele, cerebral palsy) or
Acquired (arthritis, traumatic spinal cord injuries)
and concurrent urinary calculi
• Problems:
o Positioning for ESWL or percutaneous approaches. eg Calculi on the
concave side in a patient with severe scoliosis may eliminate
percutaneous puncture access between the rib and the posterosuperior
iliac spine.
o Risks for hypercalciuria
• Immobilization
• relative dehydration; inability to drink without resistance
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74. FUTURE TRENDS
• Biodegradable ureteric stents
• Improved instrumentation
• Increased use of day-case surgery
• Greater surgical intervention
o Flexible ureteroscopy
• More critical use of ESWL with fewer retreatments
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75. CONCLUSION
• Urinary calculi is of increasing burden in developing
Countries with urbanization. There is limitation in the
management, due to limited resources. Most
presentation in our environment are infected.
Mainstay of treatment in most developing countries
still remain surgery.
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76. REFERENCES
• SMITH’S GENERAL UROLOGY, “URINARY STONE DISEASE”
17TH EDITION, McGraw-Hill 2008 246-275
• E.A Badoe ET AL, “Principles and Practice of surgery
including pathology in the tropics” 4th edition, Assembly
of God Literature Center ltd, 2009.
• M.A.R Al-Fallouji; “Postgraduate Surgery the candidate
guide”. 2nd Edition. Rced Educational and Professional
Pub. Ltd 1998
• Baley and Love’s, “ Short Practice of Surgery” 25th
edition, Edward Arnold Ltd, 2008 1295-1301
• CAMPBELL-WALSH UROLOGY, “Urinary Lithiasis” 10th
EDITION Saunders, an imprint of Elsevier Inc. 2012. Vol 2;
• .
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77. REFERENCES
• Aji S A, S Alhassan et al. “Urinary Stone Disease in
Kano, North Western Nigeria” Nigerian Medical
Journal. April - June 2011. Vol. 52 Issue 2
• S.A.H Rizvi et al; “The management of stone
disease” BJU Internation 2002, 89(suppl. 1), 62-68
• Turk, T Knoll, et al “Guidelines on Urolithiasis”
European Association of Urology. 2008
• A.STEWART AND A DJOYCE. “Modern management
of renal colic” Trends in Urology Gynaecology &
Sexual Health May/June 2008
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