M.B.Ch.B., M.R.C.S., Ph.D.(Uro.), C.A.B.(Uro), F.J.M.C.(Uro.). بسم الله الرحمن الرحيم Renal Stone Disease 2017-2018 د. نعمان هادي سعيد M.B.Ch.B., M.R.C.S., Ph.D.(Uro.), C.A.B.(Uro), F.J.M.C.(Uro.).

Epidemiology Gender : Male/female : 2 - 3 times Urinary calculi are the third most common affliction of the urinary tract, exceeded only by urinary tract infections and pathologic conditions of the prostate Gender : Male/female : 2 - 3 times Age : No age is exempted but stone occurrence is relatively uncommon before 20 year of age, the peak incidence in the fourth to sixth decades of life ( 50% of patients present between 30-50 years of age) Stone recurrence rates can be as high as 50% within 5 years

Etiology 1-Dietetic..deficiency of vitamin_A causes desquamation of the urothelium 2-Altered urinary solutes & colloids ..Dehydration leads to an increased concentration of urinary solutes &cause them to precipitate. 3-Decreased urinary citrate.. Normally 300-900 mg/24hr.

4-Renal infection. 5-Inadequate urinary drainage & urinary stasis functional & anatomical abnormalities of the urinary tract. 6-Prolonged immobilization. 7-Hyperparathyroidism.

Risk Factors Crystalluria Socioeconomic Factors: Renal stones are more common in affluent, industrialized countries Diet : Diet changes, with an increase in saturated and unsaturated fatty acids, an increase in animal protein and sugar, and a decrease in dietary fiber, vegetable protein, and unrefined carbohydrates. Fluid intake and urine output may have an effect on urinary stone disease.

Occupation: Individuals with sedentary occupations such as those in managerial or professional positions, Physicians and other white-collar workers have an increased incidence of stones compared with manual laborers. Heat exposure and dehydration constitute occupational risk factors for stone disease as well. Climates: A higher prevalence of stone disease is found in hot, arid, or dry climates such as the mountains, desert, or tropical areas. Family History A family history of urinary stones is associated with an increased incidence of renal calculi.

Types of Renal Calculus Calcium Calculi (( like calcium oxalate)): 80-85% of all urinary stones are calcareous. Phosphate calculus: Usually calcium phosphate , sometimes magnesium ammonium phosphate “Struvite “, They frequently present as renal staghorn calculi”, they are infection stones associated with urea-splitting organisms. Uric acid & Urate calculi: are hard smooth &often multiple. Pure uric acid stones are radiolucent.

Cystine calculi: uncommon, occur with congenital error of metabolism Cystine calculi: uncommon, occur with congenital error of metabolism.. multiple, very hard, pink or yellow. Xanthine calculi: very rare ,smooth & round. Indinavir: Protease inhibitors are a popular and effective treatment in patients with acquired immunodeficiency syndrome (AIDS). Rare: Silicate stones , Triamterene stones, matrix stones.

Clinical Features Symptoms are variable Silent calculus: Even large staghorn calculi may cause NO symptoms for long period. If they are bilateral uremia may be the first indication of their presence , although 2ry infection usually gives symptoms first.

Pain: Occurs in 75% of patients Renal colic and noncolicky renal pain are the 2 types of pain originating from the kidney. Fixed Renal Pain Is located posteriorly in the renal angle, anteriorly in the hypochondrium or in both. Ureteric Colic Agonising pain passing from the loin to the groin. It starts suddenly causing patient to move around trying to find comfort . Attack of colic rarely lasts more than 8 hours Ureteric colic is often caused by stone entering the ureter or occur when a stone is being lodged in the PUJ.

Hematuria: Intermittent gross hematuria or occasional tea-colored urine (old blood). Most patients will have at least microscopic hematuria. Complete ureteral obstruction presents without hematuria.

Infection :Magnesium ammonium phosphate (struvite) stones are synonymous with infection stones. They are commonly associated with Proteus, Pseudomonas, Providencia, Klebsiella, and Staphylococcus infections. Calcium phosphate stones (brushite stones ) is another infection stone. Fever: The association of urinary stones with fever is a relative medical emergency. Nausea and Vomiting

Clinical examination Abdominal Exam.: Renal Angle Tenderness +ve. Palpable swelling in the loin in case of hydronephrosis or pyonephrosis. Sometimes Rigidity of lateral abdominal muscles.

Investigations Laboratory Investigations: GUE (general urine examination) C&S (urine culture &sensitivity) KFT (kidney function test) CBC (complete blood count)

Investigations(cont.) Radiological investigations (imaging studies): U/S (Ultrasound Scanning). KUB (kidney, ureter, &bladder): 90% of urinary stones are radioopaque. Excretory Urography (intravenous Urography IVU, intravenous pyelograpgy IVP). Retrograde Pyelography. Computed Tomography (CT scan). Magnetic Resonance Imaging (MRI). Nuclear Scintigraphy.

Ultrasound

KUB

KUB ---------------Radioisotope study

Double J (DJ) stent

Scout radiograph(KUB) demonstrating left renal calculus with double-J ureteral stent in place. Skeletal fetal structures can be appreciated in this pregnant patient

KUB

CT - scan

Differential Diagnosis A full differential diagnosis of the acute abdomen should be made, including: - Acute appendicitis - Ectopic and unrecognized pregnancies - Ovarian pathologic conditions including twisted ovarian cysts - Diverticular disease of the colon - Bowel obstruction - Biliary stones with and without obstruction - Peptic ulcer disease - Acute renal artery embolism - Abdominal aortic aneurysm

Treatment of Renal Calculi Conservative Observation. Methods of Stone Removal: ESWL(Extracorporeal Shock Wave Lithotripsy). Endoscopic Intervention (cystoscopy, ureteroscopy & nephroscopy). PCNL (Percutaneous Nephrolithotomy). - Laparoscopic Surgery. - Open Surgery.

Conservative Observation Spontaneous passage depends on stone size, shape, location, and associated ureteral edema and distal obstruction. Ureteral calculi 4-5 mm in size have a 40 - 50% chance of spontaneous passage. The vast majority of stones that pass do so within a 6-week period after the onset of symptoms.

Dissolution Agents Oral alkalinizing agents include sodium or potassium bicarbonate and potassium citrate, especially effective with pH-sensitive calculi as in uric acid and cystine lithiasis. Orange juice alkalinizes urine Struvite stone dissolution requires acidification of urine.

Extracorporeal Shock Wave Lithotripsy ESWL Factors found to be associated with poor stone clearance rates: - Factors related to the stones: Stone size & number ( stone burden): Large renal calculi (mean 2 cm & more) Stone composition: too hard and too soft stone (mostly calcium oxalate monohydrate, cystine)

-Factors related to the kidneys: Stones within dependent position (in the lower pole) or obstructed portions of the collecting system like PUJ obstruction. -Factors related to the patient: Obesity or a body habitus that inhibits imaging, and unsatisfactory targeting of the stone.

Contraindications to ESWL: Absolute CI: -Pregnancy. Relative CI: - Patients with abdominal aortic aneurysms - Uncorrectable bleeding disorders should not be treated with ESWL. -Hypertension. -Patient with arrhythmia on pacemaker.

Complications of ESWL: Pain: NSAID as diclofenac or narcotics are given Perirenal hematomas Severe pain unresponsive to routine medications should alert the physician for this possibility. Fragment impaction (Steinstrasse or stone street): in to the ureter especially in large stone fragmentation. Infection Antibiotics before ESWL. Hematuria

Perinephric Hematoma

Endoscopic with lithotripsy Laser lithotripsy

Endoscopic Pneumatic Lithotripsy Endoscopic Ultrasonic Lithotripsy

PerCutaneousNephroLithotomy(PCNL) Small stones may be grasped under vision &extracted in whole. Large stones are fragmented & removed. Sometimes combined with ESWL in the treatment of staghorn calculi.

Complications of PCNL Hemorrhage from punctured renal parenchyma. Perforation of pelvicalysial system & extravasation of irrigant fluid. Injury to the surrounding organs. Arteriovenous fistula formation.

Open & laparoscopic surgery for Renal calculi Pyelolithotomy Nephrolithotomy partial nephrectomy Nephrectomy

Open surgery

Prevention of Recurrence The following investigations are done in bilateral & Recurrent stone: Stone analysis. Serum Ca++ & Uric Acid, parathyroid hormone. Urine a 24 hr collection for Urate, Ca++ , Phosphate & cystine. Encourage fluid intake Avoid food that contains oxalate Thank You