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RENAL CALCULI
Dr Anil Kumar
Assistant Professor
Department of Surgical Disciplines
All India Institute of Medical Sciences...
OBJECTIVE
• Anatomy of Kidney
• Causes of Renal Stones
• Types of Renal Stones
• Management of Renal Stones.
• ESWL, PCNL ...
ANATOMY
• Length – 10 to 13 cm
• Width- 5 to 7.5 cm
• Thickness- 2 to 2.5 cm
• Weight – 150 to 175 gram
• Left kidney( lar...
ANATOMY:
• Right Kidney: Lower than Left
• From anterior to Posterior: VAU.
• Right Renal Artery crosses posterior to
the ...
Esophagus (cut)
Inferior vena cava
Adrenal gland
Hepatic veins (cut)
Renal artery
Renal hilum
Renal vein
Iliac crest
Kidne...
Aorta
Renal artery
Segmental artery
Interlobar artery
Arcuate artery
Cortical radiate artery
Afferent arteriole
Glomerulus...
Cortical radiate vein
Cortical radiate artery
Arcuate vein
Arcuate artery
Interlobar vein
Interlobar artery
Segmental arte...
Renal cortex
Renal medulla
Major calyx
Papilla of
pyramid
Renal pelvis
Ureter
Minor calyx
Renal column
Renal pyramid
in re...
Ureter
Trigone
Peritoneum
Rugae
Detrusor
muscle
Bladder neck
Internal urethral
sphincter
External urethral
sphincter
Ureth...
Ureter
Trigone of bladder
Prostate
Membranous urethra
Prostatic urethra
Peritoneum
Rugae
Detrusor muscle
Bladder neck
Inte...
KIDNEY: RELATIONS
Anterior Relation
Posterior Relation
RISK FACTORS
IMMOBILITY
SEDENTARY LIFE
STYLE
DEHYDRATION
METABOLIC
DISTURBANCES
H/o OF
RENAL
CALCULI
RISK FACTORS
HIGH MINERAL CONTENT IN DRINKING
WATER
UTI & H/O FEMALE GENITAL
MUTILATION
PROLONGED INDWELLING
CATHETERISATI...
CAUSES: RENAL CALCULI
• Vitamin A Deficiency- Desquamation of epithelium- Nidus for Stone.
• Dehydration- Raise the Urinar...
CAUSES: RENAL CALCULI
• Renal Infections: Urea splitting Streptococci , Staphylococci , E. Coli & Proteus.
• Inadequate Ur...
ETIOLOGY
RANDALL’S PLAQUE
Soft tissue calcification found
in the deep renal medulla-
skirting the surface of the
epithelium of the ...
PATHOPHYSIOLOGY
•Slow urine flow, resulting in supersaturation of
the urine with the particular element that first
become ...
PATHOPHYSIOLOGY
•Damage to the lining of the urinary tract
PATHOPHYSIOLOGY
•Decreased inhibitor substances in the urine that
would otherwise prevent supersaturation and
crystalline ...
STONES:
Primary Stones
In healthy urinary tract without
any antecedent inflammation.
Formed in acid urine.
Usually consist...
TYPES OF RENAL STONES
• Calcium oxalate – Mc Type
• Phosphate stone
• Uric acid
• Xanthine
• Cysteine
TYPES OF RENAL CALCULUS:
• Calcium Oxalate: MC type of Kidney stone(85%)
• Also called as Mulberry stone
• Shape: Irregula...
PHOSPHATE CALCULUS:
• Also k/as : Struvite stone .
• Composition: Calcium, Ammonium & Magnesium Phosphate
( Triple Phospha...
PHOSPHATE CALCULUS
• Staghorn Calculi: Usually silent and
may cause progressive destruction
of renal parenchyma.
• Predisp...
URIC ACID STONE
• MC Radiolucent urinary calculi
• Formed in Acidic Urine.
• Hard in consistency, Smooth surface
• Appeara...
URIC ACID STONE
• Filling defect on X-Ray- Confirmed by CT Scan.
• Predisposing Factors for Uric Stones
-Gout
-Myeloprolif...
CYSTINE CALCULUS:
• Extremely Hard stone
• Found only in Acidic Urine
• Appearance: Hexagonal or Benzene ring
• Predisposi...
XANTHINE CALCULUS:
• Seen in Xanthinuria
• Extremely Rare stone
• Appearance : Smooth( surface) & Round
• Colour: Brick re...
CLINICAL FEATURES
• Age: 30-50 years
• Gender: More common in Male( M:F = 4:3)
• Infectious stone – More common in female....
PAIN IN RENAL CALCULI
• Fixed renal pain ( Renal angle)/ Hypochondrium.
• Nature: Excruciating & Cramping Pain.
• Radiatio...
PAIN IN RENAL CALCULI:
• Pain is almost invariably associated with Hematuria.
• Tachycardia ( Because of pain )
• Rigidity...
CLINICAL FEATURES OF RENAL STONE
• Hematuria: minimal
• Pyuria: Renal Stone Infection pressure builds up in dilated
with o...
DIETL’S CRISIS( INTERMITTENT HDN)
Acute
Renal
Pain
After some
hours
Large volume of
urine is Passed
Pain is
relieved
INVESTIGATION: RENAL STONE
• URINE: pH , Microscopic examination( RBC, PUS CELLS & CRYSTALLURIA) & Culture for urea
splitt...
INVESTIGATION: RENAL STONE
• Renal Function Test: Blood urea & Serum Creatinine.
• S . Uric acid level.
• Haemogram.
• Coa...
X-RAY KUB: RENAL STONE
• Kidney stone – looked opposite to second lumbar vertebrae( L2)
• Lateral X-Ray of Abdomen: Gall s...
OPACITIES ON PLAIN X-RAY :
CONFUSED WITH RENAL CALCULUS
Calcification of ATM-V
Adrenal Gland
Tuberculous lesion in the kid...
X-RAY : RENAL STONE
USG: SCREENING TOOL FOR RENAL
CALCULUS.
Posterior acoustic shadow Multiple renal stone:
IVP:INTRAVENOUS PYELOGRAM
• is an x-ray examination of the kidneys,
ureters and urinary bladder that uses
iodinated contra...
IVP: EARLY FILM ( 1 MIN & 5 MIN) & DELAYED
FILM
Non-
functioning left
kidney
NON-CONTRAST CT : MOST SENSITIVE
INVESTIGATION
NON-CONTRAST CT : MOST SENSITIVE
INVESTIGATION
RETROGRADE PYELOGRAM:
• Dye is injected directly into the ureter rather than into vein.
• Better delineation of anatomy of...
RETROGRADE PYELOGRAM
Cystoscopy
RADIONUCLIDE EVALUATION:
• DMSA ( Dimercaptosuccinic acid): Renal Morphology( Scarring )
First inject the DMSA into vein t...
DTPA:
MAG-3: OBSTRUCTED LEFT KIDNEY
MAG3 -
demonstrated the
obstructed left
kidney at the level of
the ureteropelvic
junction wi...
MANAGEMENT OF RENAL CALCULUS
• Conservative Treatment(4-6 weeks): Indication
• Single stone < 5 mm.
• Ureter is undilated....
MANAGEMENT OF RENAL CALCULUS:
CONSERVATIVE
• For Cystine, Calcium oxalate & Uric acid stone
• Increase fluid Intake
• Alka...
RENAL CALCULUS
• Avoid animal protein: Meat, chicken & Egg
• Take low salt diet.
• High Fibre diet
• Weight Reduction.
• T...
SURGICAL INTERVENTION: RENAL
CALCULUS
• ESWL ( Extracorporeal Shock Wave Lithotripsy)
• PCNL ( Percutaneous Nephrolithotom...
STONE & SURGERY OF CHOICE
• Stone < 2 cm: ESWL
• Stone > 2 cm : PCNL
• Staghorn Calculi: PCNL + ESWL
• Initial approach is...
ESWL:
• Principle: Bombarding of stones with High energy shock waves to disintegrate the
stones into fragments- small frag...
POSITION OF THE PATIENT CHECKED
BY USG
PATIENT ON LITHOTRIPTER: ESWL
EROSION & SHATTERING OF ESWL WAVES
SHOCK WAVES OF ESWL:
Small fragmented stones:
Shock waves breaking the
stones
ESWL
CONDITION WHERE ESWL MAY FAIL:
• Stone size > 2 cm, Multiple stone or Staghorn stone.
• Lower Calyceal location
• Marked h...
CONTRAINDICATION OF ESWL:
Absolute Relative Relative
Pregnancy UTI Obesity
Bleeding Disorder Unrelieved distal obstruction...
COMPLICATIONS OF ESWL:
• Infection – Main complication.
• Acute injury to the renal parenchyma: Hematuria & edema around t...
PCNL: PERCUTANEOUS
NEPHROLITHOTOMY
• Indication:
(a) Size of stone > 2.5 cm
( b) Multiple stones
(c) Stones not responding...
PCNL : STEPS
G/A or Regional Anesthesia
Cystoscopy & Ureteral catheterization
Instillation of radio-opaque dye to
opacify ...
PCNL :
Hollow Needle is
placed from skin to
opacity of renal
pelvic caliceal system
PCNL
Wire is inserted
through the hollow
needle – to guide the
passage of a series of
dilators
PCNL
Gradual dilatation of the
track - so that
Nephroscope can be eaisly
inserted through the
dilated track
PCNL: Nephroscope inserted into the track
PCNL
• Small stones : may be grasped under vision & extracted whole
• Larger stones:
Fragmented by USG,
Laser or electrohy...
PCNL
Put a Nephrostomy
tube in the pelvic
caliceal sytem- to
remove all the
remaining stone
subsequently
COMPLICATION OF PCNL
• Hemorrhage
• Perforation of the collecting system
• Perforation of the colon
• Perforation of the p...
OSS:RENAL CALCULUS
Positioning & Incision.
PYELOLITHOTOMY
Kidney –Mobilized & Vascular
Pedicle control
On the Pelvis: Give Longitudinal
incision over the stone
EXTENDED PYELOLITHOTOMY
Indication:
Large Staghorn
Calculi & Calyceal
Stone
NEPHROLITHOTOMY:
• Indication: Complex calculus branching into the most peripheral calyces.
• Mobilized the kidney.
• Cros...
NEPHROLITHOTOMY
Brodel’s
line
Stone
PARTIAL NEPHRECTOMY:
Indication:
• Stone in lowermost calyx
• Kidney containing stone area:
Nonfunctional.
• Xanthogranulo...
LlllllllllLaparoscopic stone
removal
Thank
Y
O
U
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Renal stone by Dr Anil Kumar, Assistant Professor, AIIMS-Patna

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Renal stone by Dr Anil Kumar, Assistant Professor, AIIMS-Patna

  1. 1. RENAL CALCULI Dr Anil Kumar Assistant Professor Department of Surgical Disciplines All India Institute of Medical Sciences, Patna
  2. 2. OBJECTIVE • Anatomy of Kidney • Causes of Renal Stones • Types of Renal Stones • Management of Renal Stones. • ESWL, PCNL & Operative concept in Brief.
  3. 3. ANATOMY • Length – 10 to 13 cm • Width- 5 to 7.5 cm • Thickness- 2 to 2.5 cm • Weight – 150 to 175 gram • Left kidney( larger ) > Right kidney
  4. 4. ANATOMY: • Right Kidney: Lower than Left • From anterior to Posterior: VAU. • Right Renal Artery crosses posterior to the IVC. • Left Renal Vein is longer than Right.
  5. 5. Esophagus (cut) Inferior vena cava Adrenal gland Hepatic veins (cut) Renal artery Renal hilum Renal vein Iliac crest Kidney Ureter Urinary bladder Urethra Aorta Rectum (cut) Uterus (part of female reproductive system) Right Renal Vein( No Tributaries) – IVC Left Renal vein Receive tributaries from- Left Adrenal , Gonadal, Phrenic & Lumbar.
  6. 6. Aorta Renal artery Segmental artery Interlobar artery Arcuate artery Cortical radiate artery Afferent arteriole Glomerulus (capillaries) Nephron-associated blood vessels Inferior vena cava Renal vein Interlobar vein Arcuate vein Cortical radiate vein Peritubular capillaries and vasa recta Efferent arteriole Path of blood flow through renal blood vessels
  7. 7. Cortical radiate vein Cortical radiate artery Arcuate vein Arcuate artery Interlobar vein Interlobar artery Segmental arteries Renal artery Renal vein Renal medulla Renal cortex Frontal section illustrating major blood vessels
  8. 8. Renal cortex Renal medulla Major calyx Papilla of pyramid Renal pelvis Ureter Minor calyx Renal column Renal pyramid in renal medulla Fibrous capsule Renal hilum (a) Photograph of right kidney, frontal section (b) Diagrammatic view
  9. 9. Ureter Trigone Peritoneum Rugae Detrusor muscle Bladder neck Internal urethral sphincter External urethral sphincter Urethra External urethral orifice Ureteric orifices Female
  10. 10. Ureter Trigone of bladder Prostate Membranous urethra Prostatic urethra Peritoneum Rugae Detrusor muscle Bladder neck Internal urethral sphincter External urethral sphincter Spongy urethra Ureteric orifices Male The long male urethra has three regions: prostatic, membranous and spongy. External urethral orifice
  11. 11. KIDNEY: RELATIONS Anterior Relation Posterior Relation
  12. 12. RISK FACTORS IMMOBILITY SEDENTARY LIFE STYLE DEHYDRATION METABOLIC DISTURBANCES H/o OF RENAL CALCULI
  13. 13. RISK FACTORS HIGH MINERAL CONTENT IN DRINKING WATER UTI & H/O FEMALE GENITAL MUTILATION PROLONGED INDWELLING CATHETERISATION NEUROGENIC BLADDER
  14. 14. CAUSES: RENAL CALCULI • Vitamin A Deficiency- Desquamation of epithelium- Nidus for Stone. • Dehydration- Raise the Urinary Solutes- Promote the Precipitation. • Reduction of Urinary Colloids: Colloids adsorb solutes & chelate calcium. • Decreased Urinary Citrate: Normal range- 300 to 900 mg /24 hr. This level maintain the Ca3(po4)2 & CaCo3 in soluble state.
  15. 15. CAUSES: RENAL CALCULI • Renal Infections: Urea splitting Streptococci , Staphylococci , E. Coli & Proteus. • Inadequate Urinary Drainage & Urinary Stasis. • Prolonged immobilization: Skeletal decalcification- Urinary Ca++ - Calcium Phosphate calculi. • Hyperparathyroidism( Parathyroid adenoma) : Hypercalcemia & Hypercalciuria- Renal calculi( Recurrent or Multiple stone) - These patients ‘ pass their skeletons in their urine’
  16. 16. ETIOLOGY
  17. 17. RANDALL’S PLAQUE Soft tissue calcification found in the deep renal medulla- skirting the surface of the epithelium of the Papilla, where they act as nucleating elements for renal stones
  18. 18. PATHOPHYSIOLOGY •Slow urine flow, resulting in supersaturation of the urine with the particular element that first become crystallized and later become stone
  19. 19. PATHOPHYSIOLOGY •Damage to the lining of the urinary tract
  20. 20. PATHOPHYSIOLOGY •Decreased inhibitor substances in the urine that would otherwise prevent supersaturation and crystalline aggregation
  21. 21. STONES: Primary Stones In healthy urinary tract without any antecedent inflammation. Formed in acid urine. Usually consist of calcium oxalate, uric acid, urates, Cystine, xanthine or calcium carbonate. Secondary Stones Are usually formed as the result of inflammation. Urine is usually alkaline as urea splitting organism are most often the causative organisms. e.g Triple phosphates stones
  22. 22. TYPES OF RENAL STONES • Calcium oxalate – Mc Type • Phosphate stone • Uric acid • Xanthine • Cysteine
  23. 23. TYPES OF RENAL CALCULUS: • Calcium Oxalate: MC type of Kidney stone(85%) • Also called as Mulberry stone • Shape: Irregular, Hard surface with sharp projection • Colour: Brown • Risk Factors: Hypercalciuria , Hypercalcemia & Hyperoxaluria. • Radio dense stone
  24. 24. PHOSPHATE CALCULUS: • Also k/as : Struvite stone . • Composition: Calcium, Ammonium & Magnesium Phosphate ( Triple Phosphate stone) • Risk factors: Alkaline urine with Proteus Infection (Infectious stone) • Surface: Smooth and Dirty white in colour. • Calculus may enlarge – Fill whole of the collecting system- Staghorn Calculi.
  25. 25. PHOSPHATE CALCULUS • Staghorn Calculi: Usually silent and may cause progressive destruction of renal parenchyma. • Predisposing Factors: -Women ( More incidence of UTI) -Foreign Body in the Urinary tract (Foley’s Catheter) -Neurogenic Bladder -BOO. • Over 10 years of follow up: Incidence of recurrence & UTI is up to 50%
  26. 26. URIC ACID STONE • MC Radiolucent urinary calculi • Formed in Acidic Urine. • Hard in consistency, Smooth surface • Appearance: Multifaceted, Irregular or Rosettes • Colour: Yellow to reddish brown. • Diagnosis: Filling defect on excretory Urogram.
  27. 27. URIC ACID STONE • Filling defect on X-Ray- Confirmed by CT Scan. • Predisposing Factors for Uric Stones -Gout -Myeloproliferative disease -Lesch- Nehan Syndrome. • Treatment Approach: Low purine diet, Hydration & Alkalization of urine -Allopurinol -Acetazolamide( If PH is < 6.5)
  28. 28. CYSTINE CALCULUS: • Extremely Hard stone • Found only in Acidic Urine • Appearance: Hexagonal or Benzene ring • Predisposing Factors: Cystinuria. • Treatment Approach: Low methionine diet -Alkalization of urine -Cystine complex agent: D-Penicillamine, Alpha-mercaptopropionylglycine(MPG) Radio-opaque
  29. 29. XANTHINE CALCULUS: • Seen in Xanthinuria • Extremely Rare stone • Appearance : Smooth( surface) & Round • Colour: Brick red • Cross section: Lamellation. • High fluid intake with Allopurinol: (Treatment Approach) Radiolucent Stone Like Uric acid
  30. 30. CLINICAL FEATURES • Age: 30-50 years • Gender: More common in Male( M:F = 4:3) • Infectious stone – More common in female. • MC Symptom- Pain ( 75%) • Haematuria ( calcium oxalate)- Very minimal • Pyuria.
  31. 31. PAIN IN RENAL CALCULI • Fixed renal pain ( Renal angle)/ Hypochondrium. • Nature: Excruciating & Cramping Pain. • Radiation: Along the course of Ureter.( Groin, Penis, Scrotum or labium) • Severity of pain is not related to the size of stone. • Pain may be worse on movement( climbing stairs) • Pain last for less than 8 hours ( In the absence of infection)
  32. 32. PAIN IN RENAL CALCULI: • Pain is almost invariably associated with Hematuria. • Tachycardia ( Because of pain ) • Rigidity of the Lateral abdominal muscle. • Tenderness on deep palpation. • Percussion over kidney: Sudden, sharp & severe pain ( stab like)
  33. 33. CLINICAL FEATURES OF RENAL STONE • Hematuria: minimal • Pyuria: Renal Stone Infection pressure builds up in dilated with obstruction collecting system Septicemia Organism injected into the Circulation
  34. 34. DIETL’S CRISIS( INTERMITTENT HDN) Acute Renal Pain After some hours Large volume of urine is Passed Pain is relieved
  35. 35. INVESTIGATION: RENAL STONE • URINE: pH , Microscopic examination( RBC, PUS CELLS & CRYSTALLURIA) & Culture for urea splitting organism • Acidic Urine: CCU ( Calcium Oxalate, Cystine & Uric Acid) • Alkaline Urine: Calcium Phosphate ( Brushite) & Struvite. • Crystalluria: Calcium oxalate Monohydrate- Dumbbell or Hourglass Appearance • Struvite – Coffin lid. Uric Acid- Multifaceted, irregular or rosettes • Cystine- Hexagonal or benzene ring
  36. 36. INVESTIGATION: RENAL STONE • Renal Function Test: Blood urea & Serum Creatinine. • S . Uric acid level. • Haemogram. • Coagulation Profile • Blood Sugar
  37. 37. X-RAY KUB: RENAL STONE • Kidney stone – looked opposite to second lumbar vertebrae( L2) • Lateral X-Ray of Abdomen: Gall stones – Anterior to Lumbar spine and renal and ureteric calculus overlie the lumbar spine. • 90 % of stones are Radiopaque. • Radiolucent stones are TIXU: Triamterene ( Antihypertensive drug), Indinavir (Protease inhibitors) , Xanthine & Uric acid stone.
  38. 38. OPACITIES ON PLAIN X-RAY : CONFUSED WITH RENAL CALCULUS Calcification of ATM-V Adrenal Gland Tuberculous lesion in the kidney Mesenteric Lymph node Walls of the Veins ( Pelvis)- Phlebolith GOAT Gall stones Ossified tip of the 12th Rib Concretion in the Appendix Tab / Foreign bodies in the alimentary canal(Cyclopenthiazide)/ Navidrex
  39. 39. X-RAY : RENAL STONE
  40. 40. USG: SCREENING TOOL FOR RENAL CALCULUS. Posterior acoustic shadow Multiple renal stone:
  41. 41. IVP:INTRAVENOUS PYELOGRAM • is an x-ray examination of the kidneys, ureters and urinary bladder that uses iodinated contrast material injected into veins. Immediately- Renal Blush of cortex area At 3 minutes- Diminished renal blush with Delineation of calyces and renal pelvis At 9-15 minutes – Contrast emptied into Ureter & bladder.
  42. 42. IVP: EARLY FILM ( 1 MIN & 5 MIN) & DELAYED FILM Non- functioning left kidney
  43. 43. NON-CONTRAST CT : MOST SENSITIVE INVESTIGATION
  44. 44. NON-CONTRAST CT : MOST SENSITIVE INVESTIGATION
  45. 45. RETROGRADE PYELOGRAM: • Dye is injected directly into the ureter rather than into vein. • Better delineation of anatomy of Kidney & Ureter. • Very useful if distal ureter is not visualized. • Exclude ureteric calculi and allow assessment of ureteric stricture. • Cystoscopy with RP: Detect most of the pathology.
  46. 46. RETROGRADE PYELOGRAM Cystoscopy
  47. 47. RADIONUCLIDE EVALUATION: • DMSA ( Dimercaptosuccinic acid): Renal Morphology( Scarring ) First inject the DMSA into vein that enter- Kidney second ( after 2-4 hours) Take image by gamma camera • DTPA( Diethylene Triamine Pentacetic Acid): Assess Perfusion & Function Less effective than MAG-3 • MAG-3 ( Mercapto-acetyl glycine ): Best for Renal Perfusion. DMSA
  48. 48. DTPA:
  49. 49. MAG-3: OBSTRUCTED LEFT KIDNEY MAG3 - demonstrated the obstructed left kidney at the level of the ureteropelvic junction with 28ml/min renographic clearance, which represented 38% of the total renal function.
  50. 50. MANAGEMENT OF RENAL CALCULUS • Conservative Treatment(4-6 weeks): Indication • Single stone < 5 mm. • Ureter is undilated. • Stone in lower third of ureter. • Evidence of downward movement. • Fluid intake : Most important as well as first step
  51. 51. MANAGEMENT OF RENAL CALCULUS: CONSERVATIVE • For Cystine, Calcium oxalate & Uric acid stone • Increase fluid Intake • Alkalization of Urine: Potassium citrate/ Sodium bicarbonate • Urinary PH: 6.5-7.0 • For Uric Acid: Allopurinol 300 mg QID • For Cystine: D-Penicillamine & Alpha – Mercaptopropionyleglycine
  52. 52. RENAL CALCULUS • Avoid animal protein: Meat, chicken & Egg • Take low salt diet. • High Fibre diet • Weight Reduction. • Tamsulosin- alpha -1 blockers ( Flowmax) : 0.4 mg for 7-10 days: • Nifedipine: CCB: May be beneficial.
  53. 53. SURGICAL INTERVENTION: RENAL CALCULUS • ESWL ( Extracorporeal Shock Wave Lithotripsy) • PCNL ( Percutaneous Nephrolithotomy) • URS ( Ureteroscopy) • Lap Stone Removal • OSS ( Open Stone Surgery) OSS: Indication: 1.Anatomical abnormality(PUJO) 2. Non functioning kidney with stone ( Nephrectomy) Types: 1. Pyelolithotomy 2.Extended Pyelolithotomy 3. Nephrolithotomy 4.Partial Nephrectomy
  54. 54. STONE & SURGERY OF CHOICE • Stone < 2 cm: ESWL • Stone > 2 cm : PCNL • Staghorn Calculi: PCNL + ESWL • Initial approach is PCNL , followed by ESWL. • 80-85% of simple renal calculi : Treated satisfactorily with ESWL.
  55. 55. ESWL: • Principle: Bombarding of stones with High energy shock waves to disintegrate the stones into fragments- small fragments pass down to ureter. • Localization of stone for bombarding – Fluoroscopy or USG • Physics of ESWL: The change in density b/w the soft renal tissue & hard stone causes release of energy at the stone surface which causes “ Compression induced tensile cracking of stone“. • Incoming Shock waves – causes fragmentation of stones- Erosion & Shattering • Gold standard / strongest Lithotripter for ESWL- Dornier Unmodified HM-3
  56. 56. POSITION OF THE PATIENT CHECKED BY USG
  57. 57. PATIENT ON LITHOTRIPTER: ESWL
  58. 58. EROSION & SHATTERING OF ESWL WAVES
  59. 59. SHOCK WAVES OF ESWL: Small fragmented stones: Shock waves breaking the stones
  60. 60. ESWL
  61. 61. CONDITION WHERE ESWL MAY FAIL: • Stone size > 2 cm, Multiple stone or Staghorn stone. • Lower Calyceal location • Marked hydronephrosis or scarring • Calyceal diverticulum • Horseshoe kidney • Difficult stone : Brushite, Hydroxyapatite, Cystine & Calcium oxalate monohydrate ( BHC-2)
  62. 62. CONTRAINDICATION OF ESWL: Absolute Relative Relative Pregnancy UTI Obesity Bleeding Disorder Unrelieved distal obstruction Severe Renal failure Cardiac Pacemakers Aneurysm Uncontrolled Hypertension Severe orthopedic deformity
  63. 63. COMPLICATIONS OF ESWL: • Infection – Main complication. • Acute injury to the renal parenchyma: Hematuria & edema around the kidney. • Chronic renal injury: Hypertension, Decrease renal function & Increase in rate of stone recurrence. • Lung Parenchymal Injury • Steinstrasse ( street of stones gravel in ureter)
  64. 64. PCNL: PERCUTANEOUS NEPHROLITHOTOMY • Indication: (a) Size of stone > 2.5 cm ( b) Multiple stones (c) Stones not responding to ESWL ( BHC-2 ) (d) Central part of staghorn stone.
  65. 65. PCNL : STEPS G/A or Regional Anesthesia Cystoscopy & Ureteral catheterization Instillation of radio-opaque dye to opacify the renal pelvic-caliceal system . Puncture site: few centimeter inferior & medial to tip of the 12th ribs
  66. 66. PCNL : Hollow Needle is placed from skin to opacity of renal pelvic caliceal system
  67. 67. PCNL Wire is inserted through the hollow needle – to guide the passage of a series of dilators
  68. 68. PCNL Gradual dilatation of the track - so that Nephroscope can be eaisly inserted through the dilated track
  69. 69. PCNL: Nephroscope inserted into the track
  70. 70. PCNL • Small stones : may be grasped under vision & extracted whole • Larger stones: Fragmented by USG, Laser or electrohydraulic Probe and removed in Pieces.
  71. 71. PCNL Put a Nephrostomy tube in the pelvic caliceal sytem- to remove all the remaining stone subsequently
  72. 72. COMPLICATION OF PCNL • Hemorrhage • Perforation of the collecting system • Perforation of the colon • Perforation of the pleura • Infections
  73. 73. OSS:RENAL CALCULUS Positioning & Incision.
  74. 74. PYELOLITHOTOMY Kidney –Mobilized & Vascular Pedicle control On the Pelvis: Give Longitudinal incision over the stone
  75. 75. EXTENDED PYELOLITHOTOMY Indication: Large Staghorn Calculi & Calyceal Stone
  76. 76. NEPHROLITHOTOMY: • Indication: Complex calculus branching into the most peripheral calyces. • Mobilized the kidney. • Cross-clamp the renal pedicle to control the bleeding. • Cool the kidney with ice pack( to increase the ischemic time) • Incision given on Brodel’s Line: Posterior & parallel to the most convex part of the kidney , where territories of the anterior and posterior branches of the renal artery meet.
  77. 77. NEPHROLITHOTOMY Brodel’s line Stone
  78. 78. PARTIAL NEPHRECTOMY: Indication: • Stone in lowermost calyx • Kidney containing stone area: Nonfunctional. • Xanthogranulomatous pyelonephritis.
  79. 79. LlllllllllLaparoscopic stone removal
  80. 80. Thank Y O U

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