THIS IS A PRESENTATION ABOUT UROLITHIASIS.

1. WELCOME

2. UROLITHIASIS
MAJOR (DR) SADDAM, MBBS, AMC
RESIDENT
DEPARTMENT OF UROLOGY
CMH DHAKA

3. INTRODUCTION
Urolithiasis is as old as mankind
The first documented cystolithotomy was described by Sushruta,
an ancient Indian surgeon in almost 600 BC.

4. EPIDEMIOLOGY
Prevalence varies from 1% to 20%
Multifactorial
Recurrence is high
50% having recurrence within the first decade of diagnosis.

5. NON-MODIFIABLE FACTORS
Age:
o For men , fourth to sixth decade.
o For women, bimodal peak in third decade and the
postmenopausal period.
Gender:
Male: Female = 2:1
Ethnic origin: More in White people
Family history: Contributes 2.5 times

6. MODIFIABLE FACTORS
Environmental factors:
More in hot and arid regions
Drugs:
Drugs can predispose to stone formation through metabolic effects
(e.g. corticosteroids, chemotherapeutic agents).

7. URINARY STONE AT DIFFERENT SITES

8. PATHOGENESIS
1. Concentration of culprit salts (eg-calcium
and oxalate) overwhelm inhibitory factors
(e.g. citrate, potassium, magnesium, Tamm–
Horsfall mucoproteins, pH changes)
2.Stasis of urine
Precipitation of Crystals
Stone Formation

9. Contd
Acidic pH precipitates the formation of uric acid stones
Alkaline pH precipitates the formation of calcium phosphate
stones.
Stasis stones are usually multiple, round and have a smooth
surface. These are called ‘milk of calcium stones
Infection also contribute to stone formation

10. TYPES OF URINARY STONES
1. Calcium oxalate stones
2. Calcium phosphate stones
3. Uric acid stones
4. Infection stones
5. Cystine stones
6. Mixed

11. CALCIUM OXALATE STONES
This is the most common type of stone(60–85%)
Hypercalciuria, hypercalcaemia, hyperoxaluria, hyperuricosuria
and hypocitraturia are known metabolic abnormalities
Primary hyperparathyroidism is the most common disease
Hyperuricosuria causes uric acid crystal formation, especially in
association with acidic urine, over which calcium oxalate crystals
aggregate.

12. Fig: CALCIUM OXALATE STONE

13. CALCIUM PHOSPHATE STONE
Pure calcium phosphate stones are rare.
Common forms seen are apatite and brushite stones.
Apatite is seen with infection and brushite stones are usually
seen with distal RTA

14. Fig: Calcium Phosphate Stone

15. URIC ACID STONES
Hyperuricosuria promotes the formation of both calcium oxalate
and uric acid stones.
Uric acid precipitates into crystals in acidic urine and remains
soluble in alkaline urine.
Common in gout and myeloproliferative disorders after cytotoxic
treatment.

16. CYSTINE STONES
1% of stones
Cystinuria is an autosomal recessive inherited disease
Cystine stones are very hard stones as a result of disulphide
bonds and do not fragment with SWL.

17. Fig: Uric acid and Cystine stone

18. INFECTION STONES
These are struvite and apatite stones.
Urease-producing bacterial (Proteus, Klebsiella, Serratia or
Enterobacter )
Staghorn calculi are infection stones that grow in a branching
pattern, taking the form of the pelvicalyceal system.

19. Fig: Staghorn Calculi

20. CLINICAL PRESENTATION
The presenting symptoms depend on the location, size and type
of stone:
May be asymptomatic
Haematuria
Ureteric colic radiating to groin, scrotum or labia
High grade fever with chills
Calculuria
Urgency and frequency.
Malaise and weight loss

21. DIAGNOSIS
History
Clinical examination
Investigations

22. INVESTIGATIONS
Urinary examination (Urine RE and CS)
Blood examination
A radiograph of the kidneys, ureters and bladder are good first-
line tests
USG
Non-contrast CT (NCCT) is the investigation of choice for the
diagnosis of stones
Other required tests to roll out the causes or effects

23. Fig: Xray KUB showing renal calculi

24. Fig: NC CT of abdomen showing renal calculi

25. METABOLIC EVALUATION
Depends on the risk associated with the recurrence of stone
formation, in child patients and bilateral stone cases.
Urinary examination is done to look at crystals and pH
Serum levels of calcium, phosphorus and uric acid
PTH

26. NON-SURGICAL MANAGEMENT OF STONE
1. Watchful waiting (<5 mm, non-obstructive, asymptomatic, lower
pole renal calculi)
2. Medical expulsive therapy (by Tamsulosin, an α1-adrenergic
adreno-receptor blocker)
3. Extracorporeal shockwave lithotripsy (ESWL)- Acoustic pulse
waves are generated and focused on the stone

27. Fig: ESWL procedure

28. SURGICAL MANAGEMENT
Indications for surgical intervention:
1. Failure of medical management
2. Impaired renal function
3. Chronic infection – staghorn calculi, matrix calculi
4. High-risk occupation or geographical location – pilots, long-
distance locomotive drivers, sailors.
5. Patient’s preference

29. SURGICAL OPTIONS
Endourology
1. Ureterorenoscopy
2. Retrograde intra renal surgery
3. Percutaneous nephrolithotomy
Non-endourological surgical management
1. Open surgery such as pyelolithotomy and
2. Anatrophic nephrolithotomy

30. Fig: Uretero renoscope

31. Contd
Ureterorenoscopy
long thin scopes
They have working channels that allow for the introduction of
energy sources, graspers and baskets.
A semi rigid URS is usually used with a pneumatic lithotripter or
laser energy device.

32. Retrograde intra renal surgery
A slimmer and more fexible URS
This procedure avoids the morbidity associated with
percutaneous nephrolithotomy (PCNL).
Laser is used as an energy source for stone fragmentation.
Indications for retrograde intrarenal surgery (RIRS),Renal stones
<2 cm, Lower pole calculi,Obesity,Musculoskeletal deformities
(e.g. kyphoscoliosis) and renal anomalies (HSK or pelvic
kidney),Bleeding diathesis.

33. Percutaneous nephrolithotomy
PCNL involves removal of renal stones by creating a track
between the skin and the pelvicalyceal system.
Fluoroscopy or US is used for localisation.
The posterolateral calyx is commonly chosen for entry
US in conjunction with pneumatic and laser lithotripsy

34. PREVENTION OF RECURRENT STONE
DISEASE
General measures advised to all patients include:
fluid intake of more than 2.5 litres per day
Dietary calcium should not be restricted
Supplemental calcium, if necessary, should be taken at meal
times
Reduce intake of animal protein and salt

35. COPMPLICATIONS IF UNTREATED
Urinary tract obstruction
Infectious complications
loss of renal function
Bilateral obstructing ureteric stones in a solitary kidney can
present with anuria
pyelonephritis, pyonephrosis, renal abscess or septicaemia.
Pyelo-enteric or cutaneous fistulae in neglected cases
 Nephron loss can occur as a result of recurrent episodes of
infection and obstruction, causing chronic renal failure.

36. CONCLUSION
Although the incidence of urinary stones has declined
progressively owing to the alleviation of poverty and the
improvement in basic nutrition, the modern world is witnessing a
steady increase in the incidence of renal calculi.
Timely intervention can eliminate the suffering of the patients.

37. QUESTIONS