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RENAL STONE DISEASE

ANALYSIS OF STONES
______________________________

Oxalate 504 (56.1%)


Triple phosphate237 (26.4%)
Phosphate 119 (13.4%)
Uric acid 38 (4.2%)
______________________________
Total 898 (100%)
AGE DISTRIBUTION OF
OXALATE STONES
160
140
120
100
Number of
80
Patients
60
40
20
0
10 20 30 40 50 60 70 80
Age in Years
FORMATION OF STONES
Urine pH/infection Renal damage Calcium/oxalate

Tissue debris

Anatomical stasis Fixed particles inhibitors

Aggregation

Stone formation
FORMATION OF STONES
1.Calcium - a) hypercalcaemia
b) hyperparathyroidism
c) hypercalciuria
2.Oxalate - G1, hyperoxalaturia
3.Cystine
4.Uric Acid
5.Infection - Urea-splitting organisms
6.Congenital / metabolic defects:
- medullary spone kidney
- renal tubular acidosis
CLINICAL PRESENTATION
1. Flank/loin pain, colicky + radiation
- haematuria
- nausea and vomiting
- chills/fever/frequency, if infected
2. Loin tenderness
3. Bilateral stones : renal failure
INVESTIGATIONS
1. IVU and DTPA
2. Serum creatinine calcium
3. Urine pH
4. 24-hour urine
5. Urine cultures
6. Stone analysis
METABOLIC ABNORMALITIES
(N = 392)
Hypercalciuria 28%
Hyperoxaluria 16%
Hyperuricosuria 14%
Cystinuria 0.5%
Hyperparathyroidism 1%
Primary oxalosis 0.25%
Renal tubular acidosis0.25%
INDICATIONS FOR TREATMENT

Presence of symptoms and / or obstructive


uropathy in a functioning kidney
Treatment of Renal Stones
Four Options 1) conservative
2) non-invasive: ESWL
3) minimal invasive : PCNL, URS
4) open surgery

New technology : morbidity, hospital stay,


invasiveness
Electromagnetic Shockwave
MANAGEMENT OF RENAL
CALCULI by ESWL

< 2cm in diameter and/or surface area < 500 mm2


Treatment : ESWL monotherapy

> 2cm in diameter and/or surface area > 500 mm2


Treatment : PCNL +/- ESWL
Combination therapy
MANAGEMENT OF RENAL
CALCULI by ESWL

> 2cm in diameter and/or


surface area > 500 mm
J Stents + ESWL with repeated
treatments required
ESWL for Staghorn Stones
PCNL + ESWL as main option
ESWL monotherapy is discouraged
Open surgery has a place for large
complete staghorn calculi
Contra-indications to the
Use of ESWL
Absolute contra-indications
Pregnancy
Untreated urinary tract infection
Distal obstruction to the stone that cannot be
bypassed by a stent
Untreated bleeding diatheses
Non-functioning kidney
PCNL
Percutaneous Nephroscope and Lithoclast
PCNL
Results of Percutaneous
Nephrolithotripsy PCNL
Indications : High stone burden or failed ESWL
Success : Stones free 82%
Insignificant fragments 15%
Failure : Stones > 4cm in diameter 3%
Traumatic AV Fistula
after PCNL
MANAGEMENT OF URETERIC
STONES
-Stones < 0.5 cm in diameter doesnt pass
spontaneously 4 to 6 weeks and /or causing
symptoms : ESWL monotherapy

-Stones > 0.5 cm in diameter & < 1 cm in


diameter : ESWL monotherapy
MANAGEMENT OF URETERIC
STONES

Stones > 1 cm in diameter : trial of ESWL


monotherapy
Patient counselled:
1. Repeat session may be necessary
2. URS/PCNL/ureterolithotomy
RESULTS OF URETROSCOPIC
LITHOTRIPSY (URS)
Achieved stone free status = 85% to 90%

Failures:
1.Access problems
2.Stone migration

Flexible URS for upper third ureteric calculi


especially in the male
Ureteric stone
suitable for ESWL
URS with
Guide wire
OPEN STONE SURGERY
2% incidence of all stone treatments
Indications:
1.Complex stone burden 38%
2.Non-functioning kidneys 20%
3.Failure of MIS 16%
4.Others 26%
Recurrent Rate 75% - 10 Years

100% - 20 Years

(Williams 1963)
PREVENTION OF STONES

1. Treatment of causes

2. Dietary manipulations

3. Medications - indication duration


DIETARY ADVICE
1. Hydration
2. Avoid oxalate-rich food
3. Avoid calcium-rich food ?
4. Avoid refined carbohydrates
5. Increase crude fibres
MEDICATIONS
1. Thiazides
2. Allopurinol
3. Antibiotics
4. Sodium bicarbonate
5. Potassium citrate
6. Magnesium salts
7. Pyridoxine
Cystine Stone
1% of stone population
Autosomal recessive
Round stones in calyces
Large staghorn stones
Hexagonal crystals
Medical Treatment - Cystine
Volume at 2.5 l/day
Increase pH to > 7.0
Decrease dietary protein
D-penicillamine, thiola
Side-effects : marrow / nephrotic
Indinavir Stone
Protease inhibitor for HIV
Not radio-opaque
Cannot see on CT scan
Poor solubility
Prophylaxis acidification of urine
Congenital Oxalosis
Autosomal recessive
Dystrophic calcifications in blood vessels
Multiple nephrocalcinosis in young
Early renal failure
Disease recur in transplanted kidney
Treatment with high dose pyridoxine
Nanobacteria
Small size 50-500 nm
Atypical, cytotoxic, filterable 0.22 m
Slow doubling time 3 days
Present in 90% human stones?
Act as the nidus
Sensitive to tetracycline

T Jarrett 1999