Renal calculi

Aetiology
1. Dietetic
Deficiency of vitamin A causes desquamation of epithelium.
The cells form a nidus on which a stone is deposited.
It is uncertain whether this mechanism is of importance other than in the
formation of bladder calculi.

2. Altered urinary solutes and colloids

Dehydration increases the concentration of urinary solutes until they are liable to
precipitate.
Reduction of urinary colloids, which adsorb solutes, or mucoproteins, which
chelate calcium, might also result in a tendency for crystal and stone formation

3. Decreased urinary citrate

The presence of citrate in urine, 300900 mg 24 h1 (1.64.7 mmol 24 h1) as
citric acid, tends to keep otherwise relatively insoluble calcium phosphate and
citrate in solution.
The urinary excretion of citrate is under hormonal control and decreases during
menstruation.

4. Renal infection
Infection favours the formation of urinary calculi.
Clinical and experimental stone formation are common when urine is infected with ureasplitting streptococci, staphylococci and especially Proteus spp.
The predominant bacteria found in the nuclei of urinary stones are staphylococci and
Escherichia coli.

5. Inadequate urinary drainage and urinary stasis

Stones are liable to form when urine does not pass freely.

6. Prolonged immobilisation
Immobilisation from any cause, e.g. paraplegia, is liable to result in skeletal decalcification
and an increase in urinary calcium favouring the formation of calcium phosphate calculi.

7. Hyperparathyroidism
Hyperparathyroidism leading to hypercalcaemia and hypercalciuria is found in 5% or less
of those who present with radiopaque calculi.
In cases of recurrent or multiple stones, this cause should be eliminated by appropriate
investigations
Hyperparathyroidism results in a great increase in the elimination of calcium in the urine.
These patients pass their skeletons in their urine.
A parathyroid adenoma should be removed before definitive treatment for the urinary
calculi.

Types of renal calculi

Oxalate calculus (calcium oxalate)
Oxalate stones are irregular in shape and covered with sharp
projections, which tend to cause bleeding.
The surface of the calculus is discoloured by altered blood.
A calcium oxalate monohydrate stone is hard and radiodense.

Phosphate calculus
A phosphate calculus [calcium phosphate often with ammonium
magnesium phosphate (struvite)] is smooth and dirty white.
It tends to grow in alkaline urine, especially when urea-splitting
Proteus organisms are present.
As a result, the calculus may enlarge to fill most of the collecting
system, forming a staghorn calculus
Even a very large staghorn calculus may be clinically silent for
years until it signals its presence by haematuria, urinary infection
or renal failure. Because they are large, phosphate calculi are
usually easy to see on radiographic films.

Uric acid and urate calculi

These are hard, smooth and often multiple.
They vary from yellow to reddish brown and sometimes have an
attractive, multifaceted appearance.
Pure uric acid stones are radiolucent and appear on an excretion
urogram as a filling defect, which can be mistaken for a
transitional tumour of the upper urinary tract.
The presence of uric acid stones is confirmed by CT.
Most uric acid stones contain some calcium, so they cast a faint
radiological shadow.
In children, mixed stones of ammonium and sodium urate are
sometimes found. They are yellow, soft and friable.
They are radiolucent unless they are contaminated with calcium
salts.

Cystine calculus
These uncommon stones appear in the urinary tract of patients with a
congenital error of metabolism that leads to cystinuria.
Hexagonal, translucent, white crystals of cystine appear only in acid urine.
They are often multiple and may grow to form a cast of the collecting
system.
Pink or yellow when first removed, they change to a greenish colour when
exposed to air.
Cystine stones are radiopaque because they contain sulphur, and they are
very hard.
Xanthine calculus
These are extremely rare.
They are smooth and round, brick-red in colour, and show lamellation on
cross-section

Clinical features
Renal calculi are common.
Approximately 50% of patients present between the ages of 30
and 50 years.
The malefemale ratio is 4:3.
Symptoms are variable and the diagnosis sometimes remains
obscure until the stone is discovered on a radiograph

Silent calculus
Even large staghorn calculi may cause no symptoms for long
periods, during which time there is progressive destruction of the
renal parenchyma.
Uraemia may be the first indication of bilateral calculi, although
secondary infection usually produces symptoms first

Pain
Pain is the leading symptom in 75% of people with urinary
stones.
Fixed renal pain is located posteriorly in the renal angle
anteriorly in the hypochondrium, or in both.
It may be worse on movement, particularly on climbing stairs.

 Ureteric colic is an agonising pain passing from the loin to the groin.
Typically, it starts suddenly causing the patient to writhe to find
comfort.
Pain resulting from renal stones rarely lasts more than 8 hours in the
absence of infection.
There is no pyrexia, althoughthe pulse rate rises because of the severe
pain.
Ureteric colic is often caused by a stone entering the ureter but it may
also occur when a stone becomes lodged in the pelviureteric junction.
The severity of the colic is not related to the size of the stone

Contd..
Abdominal examination
During an attack of ureteric colic there is rigidity of the lateral
abdominal muscles but not, as a rule, of the rectus abdominis.
Percussion over the kidney produces a stab of pain and there
may be tenderness on gentle deep palpation.
Hydronephrosis or pyonephrosis leading to a palpable swelling
in the loin is rare

Other features
Haematuria
Haematuria is sometimes a leading symptom of stone disease and
occasionally the only one.
As a rule, the amount of bleeding is small.

Pyuria
Infection is likely in the presence of stones and is particularly
dangerous when the kidney is obstructed.
As pressure builds in the dilated collecting system, organisms are
injected into the circulation and a life-threatening septicaemia can
quickly develop.
The mechanical effect of stones irritating the urothelium may cause
pyuria even in the absence of infection.

Investigation of suspected urinary stone

disease
Radiography
The KUB film shows the kidney, ureters and bladder.
When a renal calculus is branched, there is no doubt about the
diagnosis
An opacity that maintains its position relative to the urinary tract
durin respiration is likely to be a calculus.
Calcified mesenteric nodes and opacities within the alimentary
tract can sometimes be shown to be anterior to the vertebral
bodies on a lateral radiograph and hence outside the urinary
tract

Other investigation
Contrast-enhanced computerised tomography
CT, preferably spiral, has become the mainstay of investigation for
acute ureteric colic.

Excretion urography
Urography will establish the presence and anatomical site of a
calculus.
It also gives some important information about the function of the
other kidney.

Ultrasound scanning
Ultrasound scanning is of most value in locating stones for
treatment by extracorporeal shock wave lithotripsy (ESWL)

Management
Conservative management
Calculi smaller than 0.5 cm pass spontaneously unless they are
impacted.
Any surgical intervention carries the risk of complications and
needless intervention should be avoided.
Small renal calculi may cause symptoms by obstructing a calyx or
acting as a focus for secondary infection.
However, most can be safely observed until they pass

Surgical management
Preoperative treatment
If urinary infection is present, appropriate antibiotic treatment is
started and continued during and after surgery as necessary.

Operation for stone

In developed countries, most stones are treated by urologistsusing
minimal access and minimally invasive techniques.
Open operations are still needed when appropriate expertise is not
available or newer techniques have failed to clear the calculus

Modern methods
Percutaneous nephrolithotomy
This involves the placement of a hollow needle into the renal collecting system
through the soft tissue of the loin and the renal parenchyma.
A wire inserted through the needle is used to guide the passage of a series of
dilators, which expand the track into the kidney until it is large enough to take the
nephroscope used to visualise the stone
Small stones may be grasped under vision and extracted whole.
Larger stones must be fragmented by an ultrasound, laser or electrohydraulic probe
and removed in pieces.
The aim is to remove all fragments if possible, and this may take some time if the
calculus is large.
When the operation is over, a nephrostomy drain is left in the system. This
decompresses the kidney and allows repeated access if stone particles remain.
Percutaneous nephrolithotomy is sometimes combined with ESWL in the treatment
of complex (stag-horn) calculi.
The surgeon removes the central part of the stone percutaneously and the more
peripheral fragments are treated by ESWL.

 Complications of percutaneous nephrolithotomy include

1. haemorrhage from the punctured renal parenchyma this may
be profuse and difficult to control;
2. perforation of the collecting system with extravasation of saline
irrigant;
3. perforation of the colon or pleural cavity during placement of
the percutaneous track

ESWL
Extracorporeal shock wave lithotripsy
A urinary calculus has a crystalline structure. Bombarded with shock waves
of sufficient energy it disintegrates into fragments. The principle is seen at
its simplest in the original Dornier machine, in which shock waves were
generated by an electrical discharge placed at one focus of an ellipsoid
mirror.
The patient was positioned under radiographic control so that the calculus
was subjected to the full force of the shock waves concentrated at the
second focus of the mirror.
As shock waves are poorly transmitted through air, both the patient and the
shock-wave generators were immersed in a bath of water.
Modern ESWL machines do not have a water bath; the fluid is confined to the
path that the shock waves must follow to reach the kidney.
The shocks may be generated by the discharge of an array of
piezoelectric cells, and they may be aimed by ultrasound rather
than radiographic imaging

 When ESWL is successful the stone fragments must passdown

the ureter.
Ureteric colic is common after ESWL, and the patient needs
analgesia, usually in the form of a non-steroidal antiinflammatory drug such as diclofenac.
The bulky fragments of a large stone may impact in the ureter,
causing obstruction.
To avoid this, a stent should be placed in the ureter so that the
kidney can drain while the pieces of stone pass.
Occasionally, impacted fragments have to be removed
ureteroscopically

 The principal complication of ESWL is infection.

Many calculi contain bacteria, which are released from the broken stone.
It is wise to give prophylactic antibiotics before ESWL, and an obstructed
system should be decompressed by the insertion of a ureteric stent or
percutaneous nephrostomy before treatment

The clearance of stone from the kidney will depend upon the
consistency of the stone and its site.
Most oxalate and phosphate stones fragment well and, if lying in the
renal pelvis, will clear within days.
The results with harder stones, especially cysteine stones, are less
satisfactory. When treating calyceal stones, the patients should be
warned that the clearance of fragments may take months.

Open surgery for renal calculi

Operations for kidney stone are usually performed via a loin or
lumbar approach.
All of the procedures are difficult unless the kidney is fully
mobilised and its vascular pedicle controlled.
sling should be placed around the upper ureter to stop stones
migrating downwards

Pyelolithotomy
Pyelolithotomy is indicated for stones in the renal pelvis.
When the wall of the renal pelvis has been dissected free from its
surrounding fat, an incision is made in its long axis directly on to
the stone.
The stone is removed with gallstone forceps, taking care not to
break it because fragments may be difficult to retrieve.
Stone fragments in peripheral calyces may be detected by direct
palpation or by intraoperative radiography or nephroscopy.
If there is no infection, the pelvic incision is closed with
interrupted absorbable sutures.
If there is gross sepsis, a nephrostomy is essential to drain the
system.

Extended pyelolithotomy
The plane between the renal sinus and the wall of the collecting
system is developed on the posterior surface of the kidney.
This avoids major vessels and allows incisions to be made into
the calyces so that even large staghorn stones can be removed
intact.

Nephrolithotomy
If there is a complex calculus branching into the most peripheral calyces, it
may be necessary to make incisions into the renal parenchyma to clear the
kidney.
Nephrolithotomy may also be necessary when the adhesions resulting from
previous surgery make access to the renal pelvis difficult.
The renal pedicle must be temporarily cross-clamped to reduce bleeding
from the highly vascular renal tissue.
Incisions are made just posterior and parallel to the most prominent part of
the convex renal border, where the territories of the anterior and posterior
branches of the renal artery meet (Brdels line).
Cooling the kidney with ice packs or cooling coils extends the time that
the kidney can remain ischaemic without permanent damage.
All the incisions must be carefully closed with haemostatic sutures and the
patient observed after the operation for signs of reactionary hemorrhage

Additionally
Partial nephrectomy: sometimes preferable when the stone is
present in the lowermost calyx and there is associated infective
damage to the adjacent parenchyma
Note: A kidney destroyed by obstruction and infection associated
with stone disease should be removed, particularly when there is
xanthogranulomatous pyelonephritis
This stone related inflammatory mass must be removed with
particular care because it is liable to be attached to adjacent
structures such as the colon

Treatment of bilateral renal stones

Usually the kidney with better function is treated first unless
other kidney is more painful or there is pyonephrosis, which
needs urgent decompression
Silent bilateral staghorn calculi in the elderly and infirm may be
treated conservatively

Prevention of recurrence
All the stone formers investigated to exclude metabolic
factors, although the diagnostic yield is low in patients with a
single small stone
The urine of all the pts with stone should be screened for
infection
Appropriate investigations in bilateral and recurrent stone
formers:
i.

Serum calcium, measured fasting on three occasions to exclude

hyperparathyroidism
ii. Serum uric acid
iii. Urinary urate, calcium and phosphate in a 24-hr collection, the
urine should also be screened for cysteine
iv. Analysis of any stone passed

 Patients with hyperuricaemia should avoid red meats, offal and

fish, which are rich in purines, and should be treated with
allopurinol.
Eggs, meat and fish are high in sulphur-containing proteins and
should be restricted in cystinuria.
Stone sufferers should take the advice of Hippocrates and drink
plenty to keep their urine dilute.
Fluid intake should be increased appropriately to take account of
increased losses.
Drug treatment is largely ineffective except in those few patients
who are shown to have idiopathic hypercalciuria.
Bendroflumethiazide (5 mg) and a calcium-restricted diet reduce
urinary calcium