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DISCUSS THE MANAGEMENT

OF URINARY CALCULUS

DR BASHIR YUNUSSURGERY DEPARTMENT A.K.T.H

22/4/14

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OUTLINEINTRODUCTION

o ANATOMY o EPIDEMIOLOGYo RISK FACTORo TYPESo AETIOPATHOGENESIS

PRESENTATIONo EMERGENCYo ELECTIVE o ASYMPTOMATIC

MANAGEMENTo RESUSITATIONo HISTORYo EXAMINATIONo DIFFERENTIALSo INVESTIGATIONo TREATMENT

FOLLOW-UPPREVENTIONPROGNOSISSTONES IN SPECIAL SITUATIONSFUTURE TRENDS

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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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ANATOMY

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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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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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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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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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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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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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AETIOLOGY• METABOLIC CAUSES

hypercalcaemiao Primary hyperparathyroidismo Prolong immobilizationo Vitamin D intoxicationo Milk alkali syndromeo Sarcoidosiso Ectopic parathyroid hormone secretion – hypernephroma,

bronchogenic ca.

Enzyme disorderso Xanthinuriao Primary hyperoxaluria

Renal tubular syndromeso Cystinuriao Renal tubular acidosis

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AETIOLOGY

• METABOLIC Hyperuricaemia

o Idiopathic uric acid lithiasiso Gouto Myeloproliferative disorderso Low urinary output stateso Protein catabolism

• Leukemia• Cytotoxic chemotherapy

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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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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 THEORYIt claims that calculi form owing to the absence or low concentration of urinary stone inhibitors.

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PATHOGENESISINHIBITORS OF CRYSTALLIZATION• Magnesium• Citrate• Pyrophosphate• Orthophosphates• Nephrocalcin• Glycosaminoglycans• Mucopolysaccharides• Uropontin• Urinary peptides• Artificial urolithiasis inhibitors

• Methylene blue• Phosphonate ions

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THEORIES• Fix particle theory

o Randalls plaque -- renal papillao Carr microliths -- lymphatics

• Theory of mass precipitation • intranephronic precipitation • Crystallization Precipitation theory

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TYPES CALCIUM OXALATE 60% PHOSPHATE STONE 30% -forms staghorn cal.

o CALCIUM PHOSPHATE o AMMONIUM MAGNESIUM PHOSPHATEo CALCIUM AMMONIUM MAGNESIUM PHOSPHATE(triple phosph)

URIC ACID AND URATE STONES 5-10%o More found in bladder than kidneyso Related to high standard diet

CYSTINE STONE 1-3%o May aggregate to form staghorn, recurrence is common

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TYPES

• OTHERSo XANTHENE – def. of xanthene oxidaseo INDINAVIR – ARV drug relatedo SILICATE o MATRIXo TRIAMTERENE STONES All are radiolucent

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CLINICAL PRESENTATION

The clinical presentation of patient with urinary calculi depend mainly on the

o site of stoneo size of the stones,o unilateral or bilateral stone diseases,o presence or absence of associated infection

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PRESENTATION

EMERGENCYELECTIVESILENT OR ASYMPTOMATICCOMPLICATIONS

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EMERGENCY oRENAL COLICo 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 intoo the pelvis or into the bladder

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EMERGENCYoACUTE URINE RETENTIONoUROSEPSISoCALCULUS ANURIA-

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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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ASYMTOMATIC

• They are discovered incidentally during routine investigations such as urinalysis and imaging for other disorders

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COMPLICATIONS• RENAL MASS

o secondary hydronephrosiso squamous cell ca. – prolong irritationo Pyeonephrosiso Perinephric abscesso Renal abscesso Xantho granulomatous pyelonephritis

• CHRONIC RENAL FAILURE• PERIURETHRAL ABSCESS/FISTULAE

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DIFFERENTIALS• Non urological

o Appendicitiso Diverticulitiso Ectopic pregnancy,salphingitis,tortion of ovarian cysto RupturedAAAo biliary colic

• Urologicalo Pyelonephritiso Stricture,tumour,renal infarctiono Testicular tortion

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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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RESUSITATIONACUTE RENAL COLIC • PAIN –

o ANALGESIC- NSAID OR NARCOTICS• Diclofenac 100mg 2doses usu suffice in acte attack• +/- antiemetic OR

• Im pethidine 75mg + antiemetic or morphine

• FLUIDo Given iv, >3L/day if accompanied with vomiting Otherwise liberal fluid

intake

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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

• UROSEPSISo IV Fluid resusitation for correction of hypotension if presento iv antibiotics

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RESUSITATION• When acute episode subsides,

o Plain abdominal xray – 90% of stoneo Abdominal USS – 10% stone, infected hydronephrosis, solitary

obstructed kidneyo 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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RESUSITATION• INDICATIONS FOR URGENT INTERVENTION

o WHEN THERE IS STONE OBSTRUCTION ASSOCIATED WITH INFECTION.

o DECREASE RENAL FUCTIONo CACULUS ANURIA- BILATRAL OBSTRUCTION, OBSTRUCTED

SOLITARY KIDNEYo PYEONEPHROSIS

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ELECTIVE

• DETAIL HISTORY o Risk factors o Aetiologyo Complications

• PHYSICAL EXAMINATIONo May not reveal any significant findingo Hydronephrosis as renal angle masso Tenderness; lumber or iliaco A large vesical stone may be felt on bimanual examination

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INVESTIGATIONS• DIAGNOSTIC

o PLAIN X-RAY KUB- 90% of stoneso ABD USS- 10% radiolucent (uric, xanthene)o IVU- Degree of obstruction

o Degree of functiono Confirms radio- opaque stoneso Show non opaque stones as filling defecto Number of the kidneys

o Where available, non contrast helical CT scan- gold standard

• AETIOLOGYo Urinalysis-pH, rbc, microscopy- crystal sedimentso STONE ANALYSIS – for stone passedo 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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• BLOOD CHEMISTRY• RETROGRAGED PYELOGRAM

o is indicated if the kidney is nonfunctioning from acute obstruction

• X-RAY OF SMALL BONES OF THE HANDo is taken if hyperparathyroidism is suspected when subperiosteal

resorption and cystic areas may be seen

• CYSTOSCOPYo 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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TREATMENT• OPTIONS

o CONSERVATIVEo SURGICALo URETEROSCOPYo PCNLo ESWL

• INTERVENTION DEPENDS ON;o SIZE OF STONEo SITE OF STONEo AVAILABILITY OF TREATMENTo ABNORMAL ANATOMY OF THE URINARY TRACTo PATIENT CHIOCE

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CONSERVATIVE• Small stones(<5 mm)• If stone size

o <4mm 80%pass spontaneouslyo 4-6mm 50%pass spontaneouslyo >6mm only 10%pass spontaneously

• More distal the better• Pain controlled• Absence of renal failure and sepsis

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CONSERVATIVEConservative 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 passedAbsence of pain does not confirm stone expulsion

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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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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 functiono Obstruction with infectiono Stone >1cm o Stone <1cm with symptoms e.g severe pains,

haematuriao Starghorn calculio Solitary kidneyo Bilateral obstruction

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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 considerationso 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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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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APPROACHES TO THE KIDNEY

• Lumbar or simple flank incision. 

• Nagamatsu incision. 

• Thoracoabdominal incision. 

• Transperitoneal and retroperitoneal incisions. 

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OPEN SURGERY

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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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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 Sepsiso Hematuriao Transient renal dysfunctiono obstruction

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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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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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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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PCNL

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PCNL

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PCNLVarious types of lithotripters can be used for destruction and removal of renal stones as • electrohydrolic,• ultrasonic • laser probes lithotripters

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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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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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Dormia basket

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TREATMENT OPTIONS FOR BLADDER

CALCULI1.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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PREVENTION General measures

o Hydration: aim at urine output >2L/24hrso 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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PREVENTION Specific measures

o Thiazide diuretics i.e. for calcium oxalate stoneso Orthophosphateso 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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FOLLOW UP • History – symptoms• Physical examination• Metabolic analysis • Assessment of renal function – U/ECr, USS• Ensure preventive measures

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PROGNOSIS

• Renal calculi may recur especially if preventive measures are not rigorously pursued.

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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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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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STONES IN SPECIAL SITUATION

• OBESITYObesity 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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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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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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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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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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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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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