A Presentation for the undergraduatge medical Students in the Urology Department, Ain-Shams University Hospitals

1. Urology Department
Under-graduate courses
Urolithiasis
By
Dr. Ahmad A. Al-Sabbagh

2. ePIdeMIOlOgy
• Ten per cent of the population may expect to have an episode of stone
disease during their lifetime.
• The upper urinary tract is affected in most cases. Bladder stones are found
in a small proportion of men with bladder outflow obstruction.
• The incidence in children remains high in some developing countries.
• The prevalence of stones changes with age and is lower in women, although
the male: female ratio is becoming more equal.
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3. eTIOlOgy
• Diet
Tomatoes (Oxalate) Livers (Uric Acid) Milk Products (Calcium)
• Metabolic
Ca Stones: Hypercalcemia, Hypercalccuria. Hyperoxaluria
Uric Acid: Gout, Hyperuricosuria
Cystine: Autosomal recessive Disorder
Xanthine Stones: Heriditary xanthinuria
• Infection
Changes the PH of Urine (Urea Splitting Organisms → alkalinization of Urine)
• Obstruction:
Stasis & infection
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4. TyPeS Of STOneS
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5. TyPeS Of STOneS
Uric Acid Stone
Calcium Oxalate Stones
Cystine Stones Struvite Stone
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6. clInIcal PIcTUre
• Renal stones
 Loin pain. The most severe pain occurs when stones are moving,
 Asymptomatic stones often are found during radiographic or ultrasound imaging for
unrelated reasons
• Ureteric stones
 Acute colicky pain, When a ureteric stone has been present for 72 hours, the acute
pain subsides and the patient has relatively few symptoms.
 Stone Ureter may be impacted in one of the natural ureteric narrowing points (PUJ,
when crossed by the common iliac artery, intramural part)
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7. clInIcal PIcTUre
• Bladder Stones:
 Either formed in the bladder (Due to Obstruction) or descending from the upper
tract.
 Presenting with Frequency, Interruption of urine stream & Maybe terminal
hematuria
• Urethral Stones
 Mostly Migrating from above, or rarely formed in a urethral diverticulum
 Causes interruption of stream then acute retention
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8. cOMPlIcaTIOnS
• Infection
• Obstruction
• Migration
• Hematuria
• Retention (if impacted in the urethra or the bladder neck)
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9. InveSTIgaTIOnS
• Laboratory:
 Urinalysis
 Serum Calcium & Uric Acid
 Renal Function Tests
• Radiological
 KUB – 90% of Stones are Radio-opaque
 IVU: Stone appear as filling defect , obstruction & Backpressure
 CT Scan : Helpful to diagnose Radiolucent Stones & determining stone density
 Ultrasound & Radio-Isotopic Scan
• Instrumental
 Endoscopy
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10. InveSTIgaTIOnS
Urinary Bladder
Stone
Left Renal Stone
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11. InveSTIgaTIOnS
KUB Right Upper Ureteric Stone IVP
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12. InveSTIgaTIOnS
Left Renal Stone - Axial Right Renal Stone - Coronal
Right Renal Stone – 3D Reconstructive ©

13. TreaTMenT
Renal Stones:
• Conservative management of small renal stones
• Extracorporeal shockwave lithotripsy
 Effective for treating kidney stones 2 cm in maximum diameter, as long as no
obstruction to the passage of stone fragments is present.
• Retrograde Renoscopy
A laser fibre can be introduced through a flexible fibre optic reterorenoscope, which is
introduced through the urethra and bladder, and up the ureter to the renal collecting system.
Stones 1 cm in diameter can be disintegrated.
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14. TreaTMenT
Renal Stones:
• Percutaneous nephrolithotomy
 Stones 2 cm in diameter or more may be treated by percutaneous nephrolithotomy.
Under fluoroscopic control
• Open surgery
 Staghorn stones Kidneys that contribute 10% of overall renal function should usually be
removed
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15. TreaTMenT
Ureteric Stone:
• Conservative management
 Most stones 5 mm in maximum diameter are likely to pass spontaneously, with high
amounts of fluid intake & Diuretics
• Extracorporeal shockwave lithotripsy
 Less successful for ureteric stones than renal stones
• Endoscopic ureterolithotomy
 With or without stone disintegration
• Open surgery
 In case of ureteric pathology, such as stricture
• Laparoscopy Endoscopic Uretrolithotomy
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16. TreaTMenT
Bladder Stones
• Endoscopic (Cystolitholapaxy)
 In stones less than 2cm
• Surgical (Cystolithotomy):
 Larger than 2cm,
 Hard stones (Resistent for Crushing)
 Stones associated with diverticulum or Bladder neck obstruction (BPH)
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17. PrevenTIOn & MeTabOlIc WOrk-
UP
• Stone analysis
• Serum Ca & Phosphorus to exclude Hyperparathyroidism
• 24 hour collection of urine for: Ca, Oxalate, Citrate, Uric Acid
• Diet modification (Avoid diet containing the causative crystals) plus high
fluid intake
• Modifivation of Urine PH (Alkalinization in uric acid stones by oral
NaHCO3 or Acidification in phosphate stones by Vitamin C)
• Prevention & Treatment of UTI
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18. Urology Department
Under-graduate courses
Instrumentation & Endoscopy
By
Dr. Ahmad Al-Sabbagh

19. ObjecTIve
• A basic understanding of lower urinary tract anatomy and available
instruments is essential for safe and successful manipulation of the lower
urinary tract. This chapter addresses basic techniques that are used in the
practice of urology.
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20. UreThral caTheTerIzaTIOn
Indications
• Diagnostic
 Collection of urine for culture in females for in order to avoid contamination by skin
flora. not necessary in males because clean-catch specimens can be obtained
 Measurement of the postvoiding residual urine (can be performed less invasively with
ultrasonography)
 Instillation of contrast agents into the bladder and urethra for cystourethrography
 Urodynamic studies to assess bladder and urethral function
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21. UreThral caTheTerIzaTIOn
Indications
• Therapeutic
 Relief of infravesical obstruction is one of the most common therapeutic indications for
urethral catheterization (eg. prostatic enlargement)
 To drain the bladder after surgical procedures involving the lower urinary tract
 Accurately monitor urinary output.
 Intermittent catheterization (by the patient or an assistant) is a common means of
managing neurogenic bladder dysfunction
 Install medications (eg. Intravesical chemotherapy)
 Used as stents after surgery to allow healing of an anastomosis involving urethra.
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22. UreThral caTheTerIzaTIOn
 Types of Catheters
• Straight catheters rubber or latex (Robinson) and polyurethane (Nelaton)
 For one-time catheterizations
• Catheters with a curved tip (e.g., coudé catheters)
 bypass the male urethra in the presence of prostatic enlargement
• Self-retaining catheters, (Pezzer and Malecot)
 the catheter wings maintains the catheter within a hollow viscus.
• Foley-type catheters ,with the balloon mechanism.
 Two-way Foley catheters
 Three-way catheters they are used when bladder irrigation and drainage are necessary, as, for
example, in a patient with bladder hemorrhage
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23. UreThral caTheTerIzaTIOn
 Notes
 Catheter size (Outer diameter) is usually referred to using the French (Fr) scale in which
each millimeter in diameter is approximately 3 Fr.
 One should choose the smallest urethral catheter that will accomplish the purpose of
catheterization.
 Catheters made from latex or plastic (polyurethane) are not intended for longtime
drainage since theses materials react with urine and result in the formation of
"encrustations". Consequently catheters made from inert materials such as Silicone are
generally recommended whenever prolonged drainage is needed.
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24. UreThral caTheTerIzaTIOn
 Preparation
 The patient should be informed of the reason for catheterization and what to expect in
terms of discomfort.
 Sterilize and drape the external genitalia and surrounding area as for a surgical
procedure.
 Local anesthesia , such as 2% lidocaine hydrochloride jelly is injected
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25. UreThral caTheTerIzaTIOn
 Technique (Male Patient)
 The penis is placed on stretch perpendicular to the body without compressing the
urethra.
 The catheter is placed in the urethral meatus by holding the catheter at the tip.
 Gentle advancement of the catheter is performed
 As one approaches the bulbomembranous urethra one can feel the natural resistance of
the external sphincter here the patient is asked to take slow, deep breaths to relax and
allow easier catheter passage.
 If resistance is met, one should not attempt forceful catheter insertion but should apply
continuous, gentle pressure and ascertain at what level the potential obstruction exists.
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26. UreThral caTheTerIzaTIOn
 Technique (Female Patient)
 After spreading the labia, one can usually identify the urethral meatus easily, and the
catheter is placed gently into the bladder
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27. UreThral caTheTerIzaTIOn
 Difficult Catheterization
 Difficulty in catheterizing the male patient can result from a variety of causes.
 Use catheter introducers
 Use filliform followers and catheters
 If catheterization is difficult /failed / complicated (false passages) the best solution is to
divert urine by Percutaneous suprapubic cystostomy or to catheterize the bladder by the
use of urethrocystoscopy (flexible or rigid)
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28. cySTOUreThrOScOPy
 Definition
 Direct visualization of the anterior and posterior urethra, bladder neck, and the bladder
 Indications
 Diagnosis of lower urinary tract disease. (e.g.hematuria, Obstructive & Irritative Voiding
Symptoms)
 Prior to treatment of many LUT diseases e.g prior to TURP (Transurethral resection of
the prostate) or TURBT (Transurethral resection of bladder tumor)
 Access to the upper urinary tract for diagnosis and treatment
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29. cySTOUreThrOScOPy
 Equipment
 Cystourethroscopy can be performed with either rigid or flexible endoscopes.
 Rigid cystourethroscopes consist of a sheath, obturator, bridge, and telescopes.
 Constant Fluid irrigation and Illumination to visulalize most hollow viscus in the body
and for The bladder several types of irrigant fluid are available (normal saline, distilled
water, clycine.
 The image from a rigid or flexible endoscope can be transmitted to a TV monitor with
the use of a video-camera (video-cystourethroscopy).
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30. cySTOUreThrOScOPy
 Technique
 Position of the patient for rigid urethrocystoscopy: Lithotomy position. For flexible
urethrocystoscopy: Supine position
 The urethral meatus should be inspected
 The sheath of the cystourethroscope is generously lubricated
 the endoscope can be passed under direct vision with a 0- to 30-degree lens,
 Systematic inspection of the entire urethra and bladder should be performed during
cystourethroscopy.
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31. cySTOUreThrOScOPy
 Applications
• Cystolitholapaxy:
 Description: Endoscopic fragmentation of bladder stone and retrieval of the
fragments
 Instruments used: the standard urethrocystoscope + one of the stone fragmenting
instruments: stone crushing forceps (crocodile forceps) or pneumatic, laser
lithotriopsy.
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32. cySTOUreThrOScOPy
 Applications
• Bladder Biopsies
 Description: Taking a representative sample from a bladder growth endoscopically by a
biopsy forceps. The sampling is done without electric thermal energy.
 Instruments used: the standard urethrocystoscope + biopsy forceps (cold cup forceps)+
Bugbee coagulating electrode
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33. cySTOUreThrOScOPy
 Applications
• TURP (Transurethral resection of the prostate)
 Description: Resection of the prostatic adenoma by electric thermal energy. The curent
has two properties it could be cutting current i.e. used to cut the gland into small pieces
(chips) or coagulating current i.e. used to coagulate the bleeding spots
 Instruments used: the standard urethrocystoscope + the resectoscope sheath+ cutting
electrode (loop) + coagulating electrode (ball) + Working element
 Remarks: Since electric thermal energy is utilized a non-electrolyte irrigant should be
used during TURT e.g. water, glycine, sorbitol. Normal saline can not be used.
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34. cySTOUreThrOScOPy
 Applications
• Ureteroscopy and related procedures
 The ureteric orifice is identinfied
 A guide wire is introduced into the ureteric orifice through the whole ureter and up to
the kidney
 Dilatation of the intramural ureter is performed by serial telescopic dilators or balloon
dilator
 The ureteroscope is advanced into the ureter under vision and along the guide wire
 Once in the ureter the desired endoscopic procedure could be done e.g stone retrieval,
stone disintegration, endoureterotomy (cutting a ureteric stricture), taking a biopsy,
resecting a tumour…etc.
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35. cySTOUreThrOScOPy
 Applications
• Nephroscopy and related procedures:
 Description: Getting access to the inside of the kidney namely the pelvicalyceal system to
conduct a certain procedure. The commonest procedure to be be done via this route is
PCNL (percutaneous nephrostolithotomy
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36. Thank You