4. Introduction
Urinary stone disease/ calculus disease of
urinary tract
It is a problem that has plagued humans since
antiquity
Urinary stones have been seen in remains of
mummified Egyptians since 4800BC
They can be found anywhere in the urinary
tract
They display significant variations in
morphology
5. Epidemiology
It has a worldwide distribution
Prevalence is high in mountainous areas, deserts, &
tropical areas of the world
Highest prevalence in India, Pakistan & middle east
Incidence: 7—34/100 000(Nig); 2-3/100 (Western
Europe)
M/F ratio-3:1
Race : Whites>Blacks
Peak incidence: 3rd –5th decades
Bimodal incidence in female
11. Classification
Based on radiological properties
Radio opaque- oxalate, phosphate, cystine
Radiolucent- urate, xanthine, matrix
Based on number
Single
multiple
12. Classification
Oxalate stones (60%)
Mainly calcium oxalates
Formed in acidic urine
Hard, irregular, spiculated
Usually single
Yellow– dark red
Radio-opaque
13. Classification
Phosphate stones (30%)
Usually calcium phosphate /Others,(Ammonium,
Magnesium & or combined)
Smooth
Dirty white
Formed in alkaline urine
May take the shape of the structure in which it is
found. e.g. staghorn calculus
Radio-opaque
14. Classification
Uric acid & Urate stones
Usually multiple, hard & smooth
Yellow to purple
Radio-lucent
Found more in the bladder
15. Classification
Cystine stone
Multiple( may aggregate 2 form stag horn)
Soft
Yellow changes to green on exposure to light
Radio-opaque
16.
17.
18. Risk factors
Family history
Genetic
Diet
Socio-economic factors
Occupation
Sedentary life style
Climate
Stasis
Infection
Medications
20. Aetiopathogenesis
Supersaturation Theory
The central event in the formation of stone is
supersaturation of urine
Supersaturation depends on urinary pH, ionic strength,
solute concentration, and complexation
Concept of conc. product (CP), solubility product (Ksp),
formation product (Kfp)
Three major states of saturation in urine:
undersaturated, metastable, and unstable
21.
22. Aetiopathogenesis
Nucleation and crystal growth Theory
Calculus originate from crystal or foreign body
immersed in supersaturated urine
Magnesium and citrate inhibit crystal aggregation
Crystallization can potentially occur when (CP) > (Ksp)
In the presence of urinary inhibitors, precipitation
occurs only when supersaturation exceeds solubility
by 7 to 11 times
23. Aetiopathogenesis
Crystal Inhibition Theory
Calculi form owing to the absence or low
concentration of natural stone inhibitors
E.g. pyrophosphates, citrate, Mg, Tamm-Horsfall
protein, uropontin, Nephrocalcin
No absolute validity
24. Aetiopathogenesis
Matrix Theory
Non crystalline component (2-10%)
Actual role unknown
Nidus for crystal aggregation
Inhibitory role
An innocent bystander
25. Aetiopathogenesis
Fixed particle Theory
Presupposes an anchoring site to which crystals bind
Oxalate-induced injury to renal tubular epithelial
cells
Exact mechanism of oxalate-induced cell injury is
not known
26. Clinical presentation
Asymptomatic.
Accidental findings in the course of assessment of
an individual for some other pathological conditions
Sometimes even for ordinary medical exams
Symptomatic
Acute
Chronic
Acute on chronic
27. Clinical presentation
Major symptoms
Pain
Dysuria
Haematuria
Others
LUTS
Passage of stones
Recurrent UTI
Acute retention
Features of renal impairment
28. Clinical presentation
Minor symptoms
Constitutional Changes.
Fever
Headache
Loss of appetite
Nausea and vomiting
34. Treatment
Emergency presentation
Analgesics, anti-spasmodics
Antibiotics if there is evidence of infection
Relief of obstruction
Ureteral stent
Percutaneous nephrostomy
Adequate hydration
When acute attack subsides
Detail evaluation
Specific treatment
35. Treatment
Elective presentation
General measures
Watchful waiting
Dietary control
Medical
Copious fluid intake
Treat associated medical conditions
Dietary control
Use of drugs
Surgical
36. Treatment: choice
Stone factors
Stone size
Number
composition
Location
Associated obstruction, hydronephrosis,
pelviureteric junction obstruction, calyceal
diverticulum
39. Treatment –General measures
Liberal oral fluid intake
Reduce animal protein=0.8-1.0/g/kg/day
Reduce intake of oxalate rich foods
Reduce Na intake =2-3g/day or 80-100mEq/day
Reduce dairy product
Avoid stone provoking drugs -calcitriol,
probenecid
40. Treatment: Watchful waiting
At presentation, 66-75% of calculi are in the ureter,
of which 80% are in distal ureter
10-15% of calculi are bilateral
75-80% of calculi pass Spontaneously
Indicated in calculi of <5mm
Special Cases e.g. pregnancy
41. Treatment: Medical
Involves Chemolysis & MET or combination
Chemolysis involves use of oral or parenteral dissolution
agents, that alter urinary pH
Uric acid, Cystine & Struvite stones are amenable to such
Rx
E.g. Potassium citrate or Sodium citrate can be used to
alkalinize urine to pH 7.0-7.5 & cause dissolution of Uric
acid Stone
Uric acid lowering medication
42. Treatment: Medical
Medical Expulsive therapy involves use of certain
drug that relaxes tone of ureter
Calcium blockers & alpha blockers are rec. by
EAU
Specific e.g are Nifedipine, Tamsulosin,
Terazosin, & Doxazosin
43. Treatment: Surgical
Indication for active removal
Intractable pain
Obstruction
Symptomatic stone more > lcm in diameter in the
pelvis or calyx. It is unlikely to pass
A small stone that causes repeated colic or
haematuria but shows no sign of passage on X-ray
Infection
52. Conclusion
Calculus dx quite common
Long term follow-up is quite difficult
Thus, medical mgt. Often difficult to practice
Minimal access procedure for calculus removal not
readily available
Hence, open surgery remains a regular means of
intervention
53. Conclusion
Mgt of Urinary Calculi has undergone
tremendous revolution over the years
Advances in treatment has outpaced
understanding of the aetiology
It is hoped that modern approaches to its mgt
would be readily available to our teeming
population soonest
54. References
Klufio G.O; Mbonu O.O; Kidneys and ureters in Badoe
E.A. Principle and practice of surgery including
pathology in the tropics, 4th ed. 2008; 45:853-858
• Christopher G.F. The kidneys and ureters, in Bailey and
Love’s short practice of surgery, 26th ed. 2013; 75:1292-
1298
• Freddie H. The urinary bladder, in Bailey and Love’s
short practice of surgery, 26th ed. 2013; 76:1320-1322
• Ian E. Urethral and penis, in Bailey and Love’s short
practice of surgery, 26th ed. 2013; 78:1367
55. References
Marshall L.S; Urinary stone disease, in Smith’s General
Urology,17th ed. 2008; 16:264-277
Margaret S.P, Yair L.; Urinary Lithiasais: Etiology,
Epidemiolgy, and Pathogenesis, in Campbell-Walsh
urology 10th ed. 2012; 45:1257-1286
Michael N.F et al, Evaluation and Medical Management
of Urinary Lithiasis, in Campbell-Walsh urology 10th ed.
2012; 46:1287-1323
Brian R.M, James E.L; Surgical Management of Upper
Urinary Tract Calculi, in Campbell-Walsh urology 10th
ed. 2012; 48:1357-1410