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 - Uric acid - Oxalate

Alkaline - Ca phosphate - 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%)
Calcium oxalate Calcium phosphate Magnesium ammonium phosphate Uric acid Cystine Xanthine 2,8-dihydroxyadenine Silica Insoluble drugs (eg indinavir, triamterene etc)

WATER (7%)

ORGANIC MATRIX (3%)

Mucoprotein protein

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

1. 2. 3. 4.
Free-particle model Crystal nucleation Crystal growth and agglomeration Retention of critical sized particle Growth of trapped particle

Stone formation
Urine containing crystals flowing down collecting tubules Freeparticle model of stone initiation
Crystal growth and agglomeration

Fixedparticle model of stone 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 costovertebral 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 !