1. RENAL STONE DISEASE

6. ANALYSIS OF STONES ______________________________ Oxalate504 (56.1%) Triple phosphate237 (26.4%) Phosphate119 (13.4%) Uric acid 38 (4.2%) ______________________________ Total 898 (100%)

7. AGE DISTRIBUTION OF OXALATE STONES

8. FORMATION OF STONES Urine pH/infectionRenal damageCalcium/oxalate Tissue debris Anatomical stasis Fixed particles inhibitors Aggregation Stone formation

9. 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

10. 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

11. INVESTIGATIONS 1.IVU and DTPA 2. Serum creatinine calcium 3. Urine pH 4.24-hour urine 5.Urine cultures 6.Stone analysis

12. METABOLIC ABNORMALITIES (N = 392) Hypercalciuria28% Hyperoxaluria16% Hyperuricosuria14% Cystinuria0.5% Hyperparathyroidism1% Primary oxalosis0.25% Renal tubular acidosis0.25%

13. INDICATIONS FOR TREATMENT Presence of symptoms and / or obstructive uropathy in a functioning kidney

14. Treatment of Renal Stones Four Options1) conservative 2) non-invasive:ESWL 3) minimal invasive : PCNL, URS 4) open surgery New technology:  morbidity,  hospital stay,  invasiveness

18. Electromagnetic Shockwave

24. MANAGEMENT OF RENAL CALCULI by ESWL < 2cm in diameter and/or surface area < 500 mm 2 Treatment : ESWL monotherapy > 2cm in diameter and/or surface area > 500 mm 2 Treatment : PCNL +/- ESWL Combination therapy

25. MANAGEMENT OF RENAL CALCULI by ESWL > 2cm in diameter and/or surface area > 500 mm J Stents + ESWL with repeated treatments required

26. ESWL for Staghorn Stones PCNL + ESWL as main option ESWL monotherapy is discouraged Open surgery has a place for large complete staghorn calculi

27. 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

28. PCNL

29. Percutaneous Nephroscope and Lithoclast

30. PCNL

31. Results of Percutaneous Nephrolithotripsy PCNL Indications : High stone burden or failed ESWL Success:Stones free82% Insignificant fragments15% Failure:Stones > 4cm in diameter3%

32. Traumatic AV Fistula after PCNL

33. MANAGEMENT OF URETERIC STONES -Stones < 0.5 cm in diameter doesn’t pass spontaneously 4 to 6 weeks and /or causing symptoms : ESWL monotherapy -Stones > 0.5 cm in diameter & < 1 cm in diameter : ESWL monotherapy

34. 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

35. 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

36. Ureteric stone suitable for ESWL

39. URS with Guide wire

42. OPEN STONE SURGERY 2% incidence of all stone treatments Indications: 1.Complex stone burden38% 2.Non-functioning kidneys20% 3.Failure of MIS16% 4.Others26%

45. Recurrent Rate 75% - 10 Years 100% - 20 Years (Williams 1963)

46. PREVENTION OF STONES 1.Treatment of causes 2.Dietary manipulations 3.Medications - indication duration

47. DIETARY ADVICE 1.Hydration 2.Avoid oxalate-rich food 3.Avoid calcium-rich food ? 4.Avoid refined carbohydrates 5.Increase crude fibres

48. MEDICATIONS 1.Thiazides 2.Allopurinol 3.Antibiotics 4.Sodium bicarbonate 5.Potassium citrate 6.Magnesium salts 7.Pyridoxine

49. Cystine Stone 1% of stone population Autosomal recessive Round stones in calyces Large staghorn stones Hexagonal crystals

50. Medical Treatment - Cystine Volume at 2.5 l/day Increase pH to > 7.0 Decrease dietary protein D-penicillamine, thiola Side-effects : marrow / nephrotic

51. Indinavir Stone Protease inhibitor for HIV Not radio-opaque Cannot see on CT scan Poor solubility Prophylaxis – acidification of urine

52. 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

53. Nanobacteria Small size 50-500 nm Atypical, cytotoxic, filterable 0.22 ųm Slow doubling time – 3 days Present in 90% human stones? Act as the nidus Sensitive to tetracycline T Jarrett 1999