Dr hab. med. Wojciech Szewczyk CALCULOUS DISEASE Dr hab. med. Wojciech Szewczyk

Patient Characteristics <16 year old comprise 7% of cases 1:1 M:F Causes: metabolic abnormalities 50%, urological abnormalities 20%, infection 15%, immobilization 5% 1/3 have recurrence within 1 year 50% within 5 years

STONES FORMATION Kidney stones form when a substance is present in the urine in too high a concentration to remain dissolved. This is the solubility. Everyday we all need to excrete various wastes from the body. Some are excreted by the liver, but most come through the kidneys. The kidneys filter the substances out of the blood to make urine. Each litre of urine can only hold a set amount of waste so;

STONES FORMATION If too much waste is present in the blood from... Poor diet Metabolic abnormality Kidney abnormality Or too little urine is made due to... Dehydration Poor fluid intake

What are kidney stones made from? Calcium oxalate -the most common type of stone 85% Calcium phosphate -Metabolic disorders which cause bone to degrade or the kidneys to make alkaline urine can show as these types of kidney stones. Uric Acid 5-15% Xantine 1% Invisible in X-ray (radiolucent)

PHOSPHATE STONES IN ALKALINE URINE ¯ ENLARGES RAPIDLY ¯ TAKE SHAPE OF CALYCES ¯ STAGHORN ®

URIC ACID STONE FORMATION Like any stone, uric acid stones form when too much uric acid is present in the urine to remain dissolved. Uric acid stones form quickly as there are no known inhibitors in human urine to cope with fluctuation in output. A short period of dehydration in a susceptible individual is enough to begin stone formation. A sudden uric acid load from food can also precipitate a new stone. This means that what you eat and drink directly affects your chance of developing stone

Organ meats Liver, kidney, brains, sweetbreads what you eat and drink directly affects your chance of developing stone Shellfish Lobster, crayfish, prawns, mussels, oysters, crabs, scallops.  Organ meats Liver, kidney, brains, sweetbreads  Red meat Any red meat. Especially game.  Vegetables Peas, beans  Fish Anchovies, mackerel, sardines, herring.

URIC ACID STONE TREATMENT Urine alkalisation Drink enough water  Limit your protein intake  Don't eat too much uric acid   Avoid excessive alcohol  Check your uric acid level in the blood Urinary supersaturation of salts in concentrated urine Atleast drink 3 lits to avoid stone formation

ACUTE RENAL COLIC one of the most painful of the urologic disorders, are not a product of modern life. Scientists have found evidence of kidney stones in a 7,000-year-old Egyptian mummy.

ACUTE RENAL COLIC Acute renal colic (severe colicky flank pain radiating to groin, scrotum, labia) · Nausea, vomiting · Restlessness (trying to find comfortable position to ease the pain) · Dull pain (ill-defined, lumbar, abdominal, intermittent pain) · Frequency (frequent urination) · Gross hematuria (blood in urine visible to naked eye, usually there is pain) · Fever (when complicated by infection)

Critical size 5 mm~ 90% < 5 mm and located in the lower ureter pass spontaneously 15% pass if between 5 and 8 mm 95% >8 mm become impacted generally requiring lithotripsy or surgical removal 75% of stones are located in the distal third of the ureter

Places for obstruction

ACUTE RENAL COLIC Often, it is very important during this process to be drinking fluids and taking pain medication as needed (diclofenac sodium 50mg TTD) Intravenous pyelography (IVP) has some contraindications (dehydration, age>70, diabetes, increased serum cretinine, non steroidal anti-inflammatory drug) Alpha - blocker Mandatory (KUB-x ray and USG) CT with contrast infusion

USG During pregnancy, children May misses stones < 5mm Less sensitive in middle ureter Overall low sensitivity/specificity for stones 98% sensitive for hydronephrosis, however 22% of cases not associated with obstruction

VERY IMPORTANT infection occasionally occurs in the presence of an obstructive stone. A history of fever and chills strongly suggests superimposed infection and is a urologic emergency. It is imperative to do an IVP or an ultrasound study in these cases Sterile pyuria strongly suggests renal tuberculosis; confirmation acid-fast bacilli

STONES REMOVAL Open operations = pyelolithotomy, ureterolithotomy, cystolithotomy – nowadays performed in 2-3% So called modern techniques = PCNL, URL, ESWL – performed in 95-96%

Bladder stones different from renal stones almost exclusively elderly men most often complication of other urologic disease (Proteus). The other common indwelling catheter May complain of sudden interruption of the urinary stream. This strongly suggests a vesical stone that intermittently obstructs the bladder outlet

PerCuteneous NephroLithotomy This procedure is done to remove large kidney stones with a keyhole approach With PCNL large stones can be removed in a single operation in most cases Most patients recover and return to activity quickly

PCNL PROCEDURE After a general anaesthetic is given a tube is placed inside the kidney by looking in the bladder with a cystoscope This tube is used to fill the kidney with a special dye seen on Xray. You are then placed on your abdomen and the kidney is located with Xray A cut of 1.5cm is needed on the skin for this

PCNL PROCEDURE A needle puncture is made into the kidney and a wire inserted through this. The wire is used as a guide to allow a tract to be dilated to about 1cm across

PCNL PROCEDURE – XRay VIEW A stone can be destroyed by ultrasonic device Pneumatic device Laser device Removed with forceps if stone is small enough

PCNL PROCEDURE Once inside the kidney a telescope (nephroscope) is inserted and the stone visualized The stone is broken up into fragments as required The fragments are removed

PCNL PROCEDURE – STONE DISINTEGRATION Lithoclast is one of the most powerful devices but you must remove stone fragments with forceps It works like pneumatic hummer

PCNL PROCEDURE – Nephrostomy tube is left in situ Nephrostomy tube is left in situ for 24 hours and then removed Mo.- admission to the hospital and PCNL Tue.-removal of the nephrostomy Wed. – home sweet home

PCNL PROCEDURE – removal of staghorn stone Sometime it is not possible to remove whole stone through single nephrostomy channel

PCNL PROCEDURE – removal of staghorn stone Then you need to left in situ a nephrostomy tube and create additional puncture and dilation

PCNL PROCEDURE – removal of staghorn stone Note the both side staghorn stones Left side stone will be operated

What are the possible complications? Generally speaking the risks of PCNL increase with the size of the stone, as operating times increase. Breaking up a large stone into removable fragments also increases the chance of some damage occurring to the kidney.

What are the possible complications? Bleeding - some bleeding is normal. Heavy bleeding is uncommon (1%) Infection of the urine is not uncommon before the operation. Some stones have bacteria trapped inside them which are released during the operation.

What are the possible complications? Bowel injury - an abnormally positioned bowel can be damaged during needle puncture. About 2% of people have this anomaly, but bowel injury is much less common Absorption of large fluid volumes Mechanical damage of kidney – rare but sometime an open operation is needed

Extracorporal ShockWave Lithotripsy This procedure is to break up stones in the kidney of less than 2cm in size It can also be used for stones in the ureter although other techniques may be preferable

Extracorporal ShockWave Lithotripsy Lithotripsy involves using sound waves to break kidney stones. The sound wave travels through the body but cannot pass through the stone. The stone has to absorb the energy, which causes it to break, as if it was being directly hit. You will need to lie very still on the bed of a lithotriptor to allow the sound wave to be focused effectively. You will have a drip placed and some pain-killer given. A cushion filled with fluid is raised under the table to rest under the kidney

Extracorporal ShockWave Lithotripsy Initially waves of low power are used, building up gradually in strength. Approximately 2000 pulses are delivered to the stone. A tapping sound is heard throughout the treatment

Extracorporal ShockWave Lithotripsy The fragments are left to pass The aim is for fragments to be very small and pass unnoticed. Some stones are harder than others and split rather than crumble. This is the main limitation of the technique. Success rates for ESWL are less than PCNL for this reason, however they do avoid any cut on the skin and the subsequent risks.

WHAT AFTER ESWL ? Renal colic hydronephrosis

WHAT AFTER ESWL ?

What are the possible complications? Pain - minimized by the anaesthetist Bruising - either to the skin or kidney Skin break - this is more common in thin patients Bleeding - uncommon. Bruising of the kidney can show as blood in the urine Renal colic - passage of stone fragments may be painful if they do not break to small enough pieces

UReteroLithotripsy This operation is for the treatment of stones in the ureter, or kidney. Stones are usually less than 2cm in size The operation is performed either via a mini rigid or a mini flexible telescope (2.5mm) introduced through the penis after appropriate anaesthesia. No cut is made on the skin and no scars result

UReteroLithotripsy Ureteroscope rigid or flexible

UReterorenoLithotripsy

STONES FORMATION – risk factor for recurrent stone formation Oneset od disease early in life <25yr Strong family history Diseases associated eith stone formation Hyeprparathyroidism Renal tubular acidosis Crohn’s disease Hyperoxaluria Intestinal resection

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