Dr. Abdellatif Zayed UROLITHIASIS

Urinary Stones are the third most common affliction of the urinary tract, exceeded only by UTI and pathologic conditions of the prostate. 2-4% of general population 2-4% of general population

Age: peak age years. Sex: male : female = 3-1 Genetic: family history is +ve in 25% of recurrent stone cases.

Climate and Temp High temp results in concentrated urine and more tendency to crystallization. High temp results in concentrated urine and more tendency to crystallization. The highest incidence is 1-2 months after the maximal mean annual temp. The highest incidence is 1-2 months after the maximal mean annual temp.

If urinary constituents are similar in each kidney and if there is no evidence of obstruction, why do most stones present in a unilateral fashion? If urinary constituents are similar in each kidney and if there is no evidence of obstruction, why do most stones present in a unilateral fashion? stone recurrence rates can be as high as 50% within 5 years. stone recurrence rates can be as high as 50% within 5 years.

Pathogenesis 1. Supersaturation theory: The concentration at which saturation is reached and crystallization begins is called solubility product (Ksp). The concentration at which saturation is reached and crystallization begins is called solubility product (Ksp). It is affected by temp, pH and presence of other substances in solution. It is affected by temp, pH and presence of other substances in solution. Any conditions that makes the urine more concentrated may lead to stone formation. Any conditions that makes the urine more concentrated may lead to stone formation.

2. Inhibitors lack : disturbed colloid-crystalloid ratio such as mucin and nucleic acid, and Citrate, Mg, 3. Matrix Theory: Unlike stones on the road, In each little stone there is an organic scaffold supporting the fill of crystalline precipitate

The amount of the noncrystalline matrix component of urinary stones ranges from 2% to 10% by weight. The amount of the noncrystalline matrix component of urinary stones ranges from 2% to 10% by weight. A matrix stone can be associated with chronic UTI and has a gelatinous texture. A matrix stone can be associated with chronic UTI and has a gelatinous texture. Matrix stones are usually radiolucent (DD: clots, tumors, and fungal balls). Matrix stones are usually radiolucent (DD: clots, tumors, and fungal balls).

Types of the Stone Most of stones are mixed 1. Calcium Oxalate stone 2. Calcium phosphate stone 3. Uric acid stone (5% of cases, Radiolucent) 4. Struvite or infection stone (MAP) 5. Cystine stone (1% of all cases, Familial, Radio-opaque because it contain sulphur)

Risk Factors 1. Excess Calcium in urine Idiopathic hypercalcuria Idiopathic hypercalcuria Hyperparathyroidism Hyperparathyroidism Losing Calcium because of inactivity Losing Calcium because of inactivity 2. Excess Oxalate in urine Congenital Hyperoxaluria (rare disease) Congenital Hyperoxaluria (rare disease) Surgical removal or illness of last feets of ileum Surgical removal or illness of last feets of ileum

3. Hyperuricosuria (uric acid stone) Congenital error of tubular function Congenital error of tubular function Gout (Hyperuricemia) Gout (Hyperuricemia) Breaking down of large volume of protein e.g. Bulky tumors and Chemotherapy Breaking down of large volume of protein e.g. Bulky tumors and Chemotherapy

3. UTIs due to urease producing organisms such as Proteus or Klebseilla (Struvite or infection stone) The high ammonium results in an alkaline urine The high ammonium results in an alkaline urine Magnesium-Ammonium- Phosphate (MAP) is insoluble in alkaline urine. Magnesium-Ammonium- Phosphate (MAP) is insoluble in alkaline urine. It grows at high rate (Stag-Horn stone) It grows at high rate (Stag-Horn stone)

Clinical features 2% discovered accidentally 2% discovered accidentally Renal pain Renal pain Hematuria Hematuria GIT symptoms (nausea, vomiting) due to common innervations by celiac trunk. GIT symptoms (nausea, vomiting) due to common innervations by celiac trunk.

Lab. investigations 1. Blood tests: routine chemistries + serum Ca + uric acid. 2. Urinalysis: Ph > 7 + phosphate crystals suggests calcium phosphate or struvite calculi Ph > 7 + phosphate crystals suggests calcium phosphate or struvite calculi Hexagonal cystine crystals is diagnostic for cystinuria Hexagonal cystine crystals is diagnostic for cystinuria Uric acid crystals and calcium oxalate crystals are often normal Uric acid crystals and calcium oxalate crystals are often normal

Radiology Investigations 1. KUB: will identify radiopaque stones but will miss radiolucent stones and will not detect obstruction. 2. U.S can detect radiolucent stones but may miss small stones and uretral stones. Combination U/S & KUB: comparable to non contrast spiral CT. Combination U/S & KUB: comparable to non contrast spiral CT.

3.IVU Not useful if the kidney is not functioning or during pain. Not useful if the kidney is not functioning or during pain. Nephrotoxic Nephrotoxic Contraindicated if serum creatinine >2.5mg/dl. Contraindicated if serum creatinine >2.5mg/dl. Allergic reactions to contrast is common. Allergic reactions to contrast is common. Takes longer time than CT Takes longer time than CT

4. Spiral CT: The imaging of choice in patients with renal colic The imaging of choice in patients with renal colic No contrast complications No contrast complications No need to asses kidney function before use No need to asses kidney function before use May show other causes of acute abdominal pain May show other causes of acute abdominal pain It can predict stone fragility. It can predict stone fragility.

During the attack of renal colic: Parentral strong analgesic Parentral strong analgesic Pain Killer e.g. Pethdine or morphine Pain Killer e.g. Pethdine or morphine In between the attack: Plenty of oral fluid Plenty of oral fluid Alkalization of urine except in cases of infection stone Alkalization of urine except in cases of infection stone Treatment

Spontaneous passage depends on stone size, shape, location, and associated ureteral edema Spontaneous passage depends on stone size, shape, location, and associated ureteral edema Ureteral calculi 5 mm in size have a 50% chance of spontaneous passage. In contrast, calculi >6 mm have a 6 mm have a <5% chance of spontaneous passage.

Causes pain Causes obstruction Causes obstruction Associated with infection Associated with infection Lines of treatment 1. ESWL 2. PCNL 3. Open Surgery 4. Nephrectomy Should the stone be removed?

ESWL Such shock waves occur in nature—the familiar thunderstorm with lightning (an electrical discharge) followed by thunder (an acoustic sonic boom) is an analogous situation. Such shock waves occur in nature—the familiar thunderstorm with lightning (an electrical discharge) followed by thunder (an acoustic sonic boom) is an analogous situation.

ESWL A shock wave created by electric explosion focused on the stone. the stone broken into small fragments that pass spontaneously. A shock wave created by electric explosion focused on the stone. the stone broken into small fragments that pass spontaneously.

Contraindications of ESWL 1. Gross skeletal abnormalities 2. excessive weight 3. Pregnant women 4. Large abdominal aortic aneurysms or 5. uncorrectable bleeding disorders 6. Unsuitable for large stone

Postoperative Complications Steinstrasse (stone street) Steinstrasse (stone street) Perirenal Hematomas. (0.66%) Perirenal Hematomas. (0.66%)

Per Cutaneous Nephro Lithotomy (PCNL) A tract is created percutaneously down to the Kidney under X-Ray screening control. A tract is created percutaneously down to the Kidney under X-Ray screening control.

Pneumatic Lithotrite

The stone can be fragmented using: 1. Pneumatic lithotrite 2. Laser lithotrite 3. Ultrasound lithotrite 4. Electrohydrolic lithotrite

Bilateral Renal Stones Operate on the better functioning Kidney first. Two exceptions: 1. Severe pain on the worse side 2. Presence of infection in the worse side

Pyelolithotomy

Extended Pyelolithoyomy

Anatrophic nephrolithotomy

ESWL URS ESWL

Ureteroscopic stone extraction Ureteroscopic stone extraction is highly efficacious for lower ureteral calculi. Ureteroscopic stone extraction is highly efficacious for lower ureteral calculi.

Ureterolithotomy

Bladder Stone 1. Cystolitholapaxy the stones to be broken and removed through a cystoscope. 2. Open Cystolithotomy

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