1. Dr. Robab Maghsoudi Hashemi nijad Kidney Center (HKC) Iran University Medical ciences (IUMS)

4. Epidemiology Prevalent in 3th – 4 th decade Male/Female Ratio 3/1 Infectious Stones are common in female

5. Risk Factors Age Gender Geography Family history Genetic Diet  Beverages Urine Systemic condition  Chron’s  Hyperparatyroidism  Obesity  Cout  Hypertention  Diabetes  Menopause  Bacteria

6. Dietary Risk Factors Increased Risk Oxalate Animalprotein Sedum Sucrose Fructose Calcinm Supplement Vit C Decreased Risk Calcium, dietary Potassium Phytate Fluid

7. Stone Formation Nucleation Metastable Undersaturation Ion Conc in Soln

8. Relative incidence of stone types Pure calcium oxalate 45% Calcium oxalate & phosphate 25% ‘Triple’ phosphate (infective) 20% Calcium phosphate 3% Uric acid 5% Cystine 3%

9. Oxalate Stone

10. Phosphate Stone

11. Uric Acid Stone

12. Cystine Stone

13. Causes of urinary calculi Often unknown Urinary stasis Urinary infection Idiopathic hypercalcuria?? Hyperparathyroidism Hyperuricosuria Hyperoxaluria, cystinuria etc

14. Metabolic Investigation of Urinary Calculi 24 hour urine Volume Calcium Uric acid Oxalate Citrate Spot urine pH Cystine spot test Blood tests Urea, electrolytes, creatinine Calcium, phosphate, alkaline phosphatase Uric acid, chloride, bicarbonate, plasma proteins

15. Symptoms and signs of upper tract calculi Loin tenderness Loin pain Haematuria-macro or micro radiating to groin Strangury/ dysuria

16. Pathological Effects of Renal & Ureteric Calculi Hydronephrosis Squamous change metaplasia/neoplasia Hydroureter Oedema & periureteric inflammation Hydrocalycosis Cortical atrophy & scarring Recurrent UTIs/ pyelonephritis/ perinephric abscess Haematuria

17. Signs and Symptoms of Bladder Calculi Squamous metaplasia/ neoplasia Opacity on plain x-ray Sudden interruption of urinary stream Frequency, haematuria dysuria, strangury Suprapubic/groin pain Penile pain

18. Diagnosis of urinary calculi History & Examination Kidney/Ureter/Bladder x-ray (KUB) Intravenous Urogram (IVU) Renal Ultrasound CT scan

19. Management of Urinary Calculi- Site Renal pelvis/calyces Upper ureter Mid-ureter Lower ureter Bladder & (urethra)

20. Management of Urinary Calculi - Clinical Condition of Patient Is the stone causing obstruction? Is the obstruction partial or complete? Is the contralateral kidney functioning/present? Is the serum creatinine raised? Are there signs or symptoms of sepsis? (eg pyrexia, leucocytosis, rigors etc)

21. Management of urinary calculi - Renal Percutaneous nephrolithotomy (PCNL) Extracorporeal shock-wave lithotripsy (ESWL) Flexible ureteroscopy & in-situ lithotripsy Open pyelo/nephrolithotomy Observation

22. Types of Renal Calculi Small single/ multiple calyceal stones Solitary large renal pelvic stone Branched (staghorn) calculus Staghorn with severe parenchymal damage No treatment (unless symptomatic) ESWL/ PCNL PCNL+/- ESWL ?Nephrectomy (if unilateral)

23. Percutaneous Nephrolithotomy (PCNL)

24. Extracorporeal Shockwave Lithotripsy (ESWL)

25. ESWL

26. Bilateral Staghorn Calculi

27. Effect of a Staghorn Calculus

28. Management of Urinary Calculi - Ureter Upper - Push and Bang Upper - Push and Pull Upper - In-situ ESWL Upper - ??Ureteroscopy and disintegration Middle - Treat appropriately ?upper ?lower Lower - Ureteroscopy and disintegration Lower - In-situ ESWL (if very low down) Open/Laparoscopic ureterolithotomy

29. Upper ureteric stone

30. Lower ureteric stone

31. Ureteric stone - Ureteroscopy

32. Ureteric Stone - Basketing

33. Lower Ureteric Stone

34. Lower Ureteric Stone in Basket

35. Bladder Stones - x-ray

36. Bladder Stones - endoscopy

37. Bladder Stone - Lithalopaxy

38. Bladder Stone - Lithotripsy

39. Urethral Calculus

41. Prevention of Urinary Calculi Treat specific cause eg hyperparathyroidism High fluid intake Thiazide diuretics Allopurinol (uric acid stones) Urinary alkalinization (uric acid stones) Urinary acidification (infective stones)

42. Emergency Management Infection above an obstructing ureteric stone An obstructed single functioning kidney Drain the kidney Percutaneous nephrosotomy Stenting of ureter