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UROLITHIASIS

Savenkov V. I.
Epidemiology:
Intrinsic Factors
Hereditary [runs in families]
age all ages susceptible, in elderly male BPH
Sex, M:F = 3:1 due to male anatomy
Extrinsic Factors
Geography [equator]
Colder areas tendency to form stones
Climate & seasonal factors
Water intake
Oxalate-rich diet [tomato, mangoes, tea,
strawberry]
Occupation
Etiology of Urinary Stones:
1. hypersecretion of relatively insoluble
urinary constituents e.g. hypercalciuria,
oxalates, uric acid, phosphates, cystineetc
2. physical changes in urine:
urine volume w/ N calciuria conc. of Ca
Urinary Mg : Ca ratio
Urinary pH
Acidic Alkaline
- Uric acid - Ca phosphate
- Oxalate - Ca carbonate
- Mg ammonium sulfate
Cont
3. nucleus formation
4. structural abnormalities of the urinary tract
[obstruction]
The ureters have 3 narrow points where
stones are usually found:
Pelvi-Ureteric Junction PUJ
Pelvic inlet crossing iliac vessels
uretero-vesical junction
Renal Calculi
DEFINITION:
A renal calculi is a
solid mass that
consists of collection
of tiny crystals.
There can be one or
more stones present
at the same time in
the kidney or in the
ureter or bladder
Factors affecting Stone
Formation
1. concentration of solutes
2. nucleus
- foreign body
- clot due to trauma to kidneys or
much Hemoglobinuria
- pus
- papilla in papillary necrosis
3. stagnation obstruction
Composition of Renal Calculi
MINERAL (90%) WATER ORGANIC
(7%) MATRIX (3%)
Calcium oxalate Mucoprotein
Calcium phosphate protein
Magnesium ammonium
phosphate
Uric acid
Cystine
Xanthine
2,8-dihydroxyadenine
Silica
Insoluble drugs (eg indinavir,
triamterene etc)
Classification of Urinary Stones:
Primary
Metabolic Stones- due to in-born errors of
metabolism
Cystinuria
Hyperoxaluria
Hyperparathyroidism
Idiopathic hypercalciuria
Xanthinuria
Classification of Urinary Stones:
Secondary
non-metabolic stones
Infection stones in alkaline urine
Dehydration
Urinary obstruction
Immobilization as result of:
Bone resorption & demineralization of bone &
hypercalciuria
Stagnation of urine
Urinary stone formation
Free-particle model
1. Crystal nucleation
2. Crystal growth and agglomeration
3. Retention of critical sized particle
4. Growth of trapped particle
Stone formation
Urine containing
crystals flowing
down collecting
tubules
Free- Fixed-
particle particle
model of Crystal growth model of
stone and stone
agglomeration
initiation initiation
Critical particle
trapped in tubule

Particle adheres to
damaged site on
tubule wall and
other crystals
agglomerate with it
Types of renal stone
Calcium oxalate 75%
Magnesium ammonium phosphate 10-15%
Uric acid 6%
Cystine 1-2%
OXALATE
It is end product of
endogenous amine
acid metabolism
Urinary
concentration
variable
(150-450
mmol/day)
STRUVITE
Struvite stone form
in infected urine
pH is high >7
Bacteria urease
Urea ammonia
ammonium
Large (staghorn)
calculi which may
obstruct the KUB
URIC ACID STONES
End product of
purine
metabolism
Solubility in urine
pH dependent
Normal excretion
(500-600 mg/day)
CYSTINE STONES
Mainly formed from the
amino acid cystine
These stones can be
dissolved slowly with
maintenance of high fluid
intake (5l/day)
Intake of penicillamine
which causes cystine to
be converted to more
soluble penicillamine
cystine
Staghorn Stone
Stone filling the pelvis with one or
more of the major calyces
Complain late because it doesnt cause
urinary obstruction
Renal Colic:
colicky pain starting from the costo-
vertebral angle [renal angle] radiating
to the front to the lumbar & iliac fossa
& genitalia of the same side
flank pain due to stretching of the
kidney capsule
Diagnosis
85% of stones are radio-opaque
KUB, plain X ray for radio-opaque stones
US for radiolucent + radio-opaque
IVU
Retrograde Pyelogram
CT
MRI
Isotope renal scan
EFFECTS AND COMPLICATIONS

Renal colic
Hematuria
Obstruction
Infection
Stricture
Squamous metaplasia
Complications in nephrolithiasis
Acute pyelonephritis
Chronic calculous pyelonephritis
Calculous pyonephrosis
Calculous hydronephrosis
Nephrogenic arterial hypertension
Acute renal insufficiency
Chronic renal insufficiency
Treatment
Medical
Interventional
Prevention of Recurrence
Medical Treatment
Aim:
dissolve stone
help it to pass
Dissolving stones:
Any radio-opaque stone doesnt dissolve
Uric acid stones are the only which are
known to dissolve completely
Criteria for stone to pass:
small size
smooth
solitary
Medical Therapy
1. Hydration + Diuretics
2. Spasmolitics
3. Analgesics or narcotics in renal colic
4. NSAIDs
5. Antibiotics (UTI, edema of ureteric
mucosa)
6. Dissolution
Prevention of Recurrence
1. water intake [urine volume]
2. Diet regulation
- protein [uric acid stones]
- calcium [calcium stones]
3. Treatment of UTI
4. Correction of obstruction
5. Metabolic Screening once stone
removed
Interventional Treatment
ESWL Extracorporeal Shock Wave
Lithotripsy
Intracorporeal
PCNL Percutaneous Nephrolithotripsy
URS Uretero Renoscopy
Laparoscopy
Surgery
Removal of a stone from the ureter
Good Luck !

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