observers.
Mentioned in Oath of Hippocrates.
--- Content provided by FirstRanker.com ---
Over last 150 years, pattern of stone disease haschanged .
Lower tract urate calculi stil a problem in the third
--- Content provided by FirstRanker.com ---
world.
Urolithiasis denotes stones originating anywhere
in the urinary tract, including the kidneys and
--- Content provided by FirstRanker.com ---
bladder.
NEPHROLITHIASIS.
URETEROLITHIASIS.
--- Content provided by FirstRanker.com ---
CYSTOLITHIASIS.ETIOLOGY
Dietetic
--- Content provided by FirstRanker.com ---
Deficiency of vitamin A causes desquamation ofepithelium.
The cells form a nidus on which a stone is deposited.
--- Content provided by FirstRanker.com ---
Altered urinary solutes and col oidsDehydration increases the concentration of urinary
solutes
--- Content provided by FirstRanker.com ---
Reduction of urinary colloids, which adsorb solutes, ormucoproteins, which chelate calcium, might also result in
a tendency for crystal and stone formation.
--- Content provided by FirstRanker.com ---
Decreased urinary citrateThe presence of citrate in urine, 300?900 mg 24 h?1
as citric acid, tends to keep otherwise relatively
--- Content provided by FirstRanker.com ---
insoluble calcium phosphate and citrate in solution.Renal infection
with urea-splitting streptococci, staphylococci and
--- Content provided by FirstRanker.com ---
especial yProteus spp.Inadequate urinary drainage and urinary stasis
Stones are liable to form when urine does not pass
--- Content provided by FirstRanker.com ---
freely.Prolonged immobilisation
Immobilisation from any cause results in skeletal
--- Content provided by FirstRanker.com ---
decalcification and an increase in urinary calcium.HYPRECALCIURIA
Idiopathic hypercalciuria, Primary hyperparathyroidism,
Renal tubular acidosis, sarcoidosis and vitamin D
--- Content provided by FirstRanker.com ---
intoxication.
HYPREOXALURIA
Primary hyperoxaluria ,Enteric hyperoxaluria, Toxic
--- Content provided by FirstRanker.com ---
hyperoxaluria
HYPERURICOSURIA
Urinary Acidification and Alkalinization
--- Content provided by FirstRanker.com ---
Infection with urea splitting organisms.
The urea is split to ammonia, which is hydrolyzed to
ammonium hydroxide, raising urine pH to 8 to 9,
--- Content provided by FirstRanker.com ---
struvite precipitates.
Struvite stone disease has been cal ed "stone
--- Content provided by FirstRanker.com ---
cancer"The stones tend to be very large (staghorn), and
frequently result in renal damage, but patients may
--- Content provided by FirstRanker.com ---
be relatively symptom free until the stone occupies
entire col ecting system.
Cystinuria
--- Content provided by FirstRanker.com ---
An inborn error of metabolism characterized byincreased urinary excretion ofcystine,ornithine,
lysine, arginine (COLA), due to a defect in renal
--- Content provided by FirstRanker.com ---
tubular reabsorption of these amino acids.
Cystine is insoluble and precipitates in
--- Content provided by FirstRanker.com ---
concentrated urine.The stones are large ,radiolucent and recurrent.
Some drugs (triamterene, some of the older sulphas)
--- Content provided by FirstRanker.com ---
can be metabolized to insoluble compounds which
can precipitate in urine.
--- Content provided by FirstRanker.com ---
The carbonic anhydrase inhibitor, acetazolamide,causes a combined Type 1 and Type 2 RTA which
may result in nephrolithiasis.
--- Content provided by FirstRanker.com ---
Types of renal calculus
Oxalate calculus
--- Content provided by FirstRanker.com ---
(calcium oxalate)
Irregular in shape.
Covered with sharp
--- Content provided by FirstRanker.com ---
projections, which cause
bleeding.
--- Content provided by FirstRanker.com ---
The surface of thecalculus is discoloured
by altered blood.
--- Content provided by FirstRanker.com ---
Is hard and radiodense.
Phosphate calculus
--- Content provided by FirstRanker.com ---
It is smooth and dirty white.Tends to grow in alkaline urine,
especial y when urea-splitting
--- Content provided by FirstRanker.com ---
organisms are present.It may enlarge to fil most of the
col ecting system, forming a
--- Content provided by FirstRanker.com ---
staghorn calculus.
Even a very large staghorn
--- Content provided by FirstRanker.com ---
calculus may be clinical y silentfor years.
Presents with haematuria,
--- Content provided by FirstRanker.com ---
urinary infection or renal failure.
Easy to see on radiographic
--- Content provided by FirstRanker.com ---
films.Uric acid and urate
calculi
--- Content provided by FirstRanker.com ---
These are hard, smooth
and multiple.
--- Content provided by FirstRanker.com ---
They vary from yellow toreddish brown,
multifaceted.
--- Content provided by FirstRanker.com ---
Are radiolucent and
appear on IVP as a filling
--- Content provided by FirstRanker.com ---
defect, which can bemistaken for a tumour.
The presence of uric acid
--- Content provided by FirstRanker.com ---
stones is confirmed by CT.
Cystine calculus
Associated with a congenital error of metabolism that
--- Content provided by FirstRanker.com ---
leads to cystinuria.Hexagonal, translucent, white crystals of cystine appear
only in acid urine.
--- Content provided by FirstRanker.com ---
They are multiple and may grow to form a cast of the
collecting system.
--- Content provided by FirstRanker.com ---
Pink or yellow when first removed, they change to agreenish colour when exposed to air.
Cystine stones are radioopaque because they contain
--- Content provided by FirstRanker.com ---
sulphur, and they are very hard.
Xanthine calculus
Extremely rare.
--- Content provided by FirstRanker.com ---
Smooth and round, brick-red in colour, and showlamellation on cross-section.
--- Content provided by FirstRanker.com ---
Clinical featuresSilent calculus
UTI
Uraemia may be the first indication calculi.
--- Content provided by FirstRanker.com ---
Pain
MC symptom in 75% of
people.
--- Content provided by FirstRanker.com ---
Fixed renal pain is located
posteriorly in the renal
--- Content provided by FirstRanker.com ---
angle anteriorly in thehypochondrium, or in both.
It may be worse on
--- Content provided by FirstRanker.com ---
movement, particularly on
climbing stairs.
Ureteric colic is an agonising pain passing from
--- Content provided by FirstRanker.com ---
the loin to the groin.
Typically, it starts suddenly causing the patient to
--- Content provided by FirstRanker.com ---
writhe to find comfort.Pain resulting from renal stones rarely lasts more
than 8 hours in the absence of infection.
--- Content provided by FirstRanker.com ---
There is no pyrexia.
The severity of the colic is not related to the size
of the stone .
--- Content provided by FirstRanker.com ---
Haematuria
Sometimes a leading symptom of stone disease.
As a rule, the amount of bleeding is small.
Pyuria
--- Content provided by FirstRanker.com ---
Infection is dangerous when the kidney is obstructed.As pressure builds in the dilated col ecting system,
organisms are injected into the circulation and a life-
--- Content provided by FirstRanker.com ---
threatening septicaemia can quickly develop.The mechanical effect of stones irritating the
urothelium may cause pyuria even in the absence of
--- Content provided by FirstRanker.com ---
infection.
Investigation
--- Content provided by FirstRanker.com ---
Radiography
The `KUB' film shows the
--- Content provided by FirstRanker.com ---
Opacities that may bekidney, ureters and
confused with renal calculus
--- Content provided by FirstRanker.com ---
bladder.
Calcified mesenteric lymph
--- Content provided by FirstRanker.com ---
An opacity that maintainsnode
its position relative to the
--- Content provided by FirstRanker.com ---
Gallstones or concretion in
urinary tract during
--- Content provided by FirstRanker.com ---
the appendixrespiration is likely to be a Tablets or foreign bodies in
calculus.
--- Content provided by FirstRanker.com ---
the alimentary canal
Phleboliths
--- Content provided by FirstRanker.com ---
Ossified tip of the 12th ribCalcified tuberculous lesion
in the kidney
--- Content provided by FirstRanker.com ---
Calcified adrenal gland
Excretion urography
--- Content provided by FirstRanker.com ---
Also called IVP, is a radiological procedure used
to visualize abnormalities of the urinary system,
--- Content provided by FirstRanker.com ---
including the kidneys, ureters, and bladder.Procedure-IVP
An injection of x-ray contrast medium is given I/V.
The contrast is excreted via the kidneys, and the
--- Content provided by FirstRanker.com ---
contrast media becomes visible on x-rays almost
immediately after injection.
--- Content provided by FirstRanker.com ---
X-rays are taken at specific time intervals to capturethe contrast as it travels through the different parts of
the urinary system.
--- Content provided by FirstRanker.com ---
This gives a comprehensive view of the patient's
anatomy and some information on the functioning of
--- Content provided by FirstRanker.com ---
the renal system.An IVP can be performed in either emergency or
routine circumstances.
--- Content provided by FirstRanker.com ---
Emergency IVPFor patients who present to the A&E, with
severe renal colic and a positive hematuria test.
--- Content provided by FirstRanker.com ---
Patients with a positive find for kidney stones but withno obstruction are usual y discharged with a follow-
up appointment with a urologist.
--- Content provided by FirstRanker.com ---
Patients with a kidney stone and obstruction are
usual y required to stay in hospital for monitoring or
--- Content provided by FirstRanker.com ---
further treatment.Contraindications-IVP
Metformin should be to stoped 48 hours pre and
--- Content provided by FirstRanker.com ---
post procedure.ARF/CRF.
Known allergy to contrast medium.
--- Content provided by FirstRanker.com ---
Contrast-enhanced computerisedtomography
CT has become the mainstay of investigation for
--- Content provided by FirstRanker.com ---
acute ureteric colic.
Ultrasound scanning
Ultrasound scanning is of most value in locating
--- Content provided by FirstRanker.com ---
stones for treatment by extracorporeal shock
wave lithotripsy (ESWL).
--- Content provided by FirstRanker.com ---
Ureteric calculus
URETERIC CALCULUS
--- Content provided by FirstRanker.com ---
A stone in the ureter usually comes from the kidney.Most are single small stones that are passed spontaneously.
Clinical features
Ureteric colic
--- Content provided by FirstRanker.com ---
Intermittent attacks of colic.As the stone progresses to the lower ureter, loin pain is
typically referred more to the groin, external genitalia and the
--- Content provided by FirstRanker.com ---
anterior surface of the thigh.When the stone is in the intramural ureter, the pain can be
referred to the tip of the penis.
--- Content provided by FirstRanker.com ---
Strangury, the painful passage of a few drops of urine,
typically occurs with the stone in the intramural part of the
--- Content provided by FirstRanker.com ---
ureter.Haematuria
Almost every attack of ureteric colic is associated
--- Content provided by FirstRanker.com ---
with microscopic haematuria, which lasts for aday or so.
More profuse bleeding is uncommon and should
--- Content provided by FirstRanker.com ---
raise the suspicion that the colic is due to
passage of a clot.
--- Content provided by FirstRanker.com ---
When the stone becomes impacted, the attacks ofcolic give way to a more consistent dull pain, often
felt in the iliac fossa.
--- Content provided by FirstRanker.com ---
The pain may be increased by exercise and lessened
by rest.
--- Content provided by FirstRanker.com ---
Severe renal pain subsiding after a day or sosuggests complete ureteric obstruction.
If obstruction persists after 1?2 weeks, the calculus
--- Content provided by FirstRanker.com ---
should be removed because prolonged distension of
the kidney wil eventual y lead to atrophy of the renal
--- Content provided by FirstRanker.com ---
parenchyma.Impaction
--- Content provided by FirstRanker.com ---
There are five sites ofnarrowing where the
stone may be arrested
--- Content provided by FirstRanker.com ---
What are those?
Abdominal examination
--- Content provided by FirstRanker.com ---
Tenderness and some rigidity over some part of thecourse of the ureter.
On the right side is to distinguish from ?
--- Content provided by FirstRanker.com ---
The presence of haematuria does not rule outappendicitis, because an inflamed appendix can give
rise to a local ureteritis.
--- Content provided by FirstRanker.com ---
ImagingPlain abdominal radiograph.
Intravenous urography.
Spiral CT scan.
--- Content provided by FirstRanker.com ---
Cystoscopy.CONSERVATIVE
MANAGEMENT
--- Content provided by FirstRanker.com ---
Mainstay is the forced increase in fluid intake
to achieve a daily urine output of 2 liters .
--- Content provided by FirstRanker.com ---
Increased urine output has two effects-1. Mechanical diuresis
2. The dilute urine alters the supersaturation of
stone components.
--- Content provided by FirstRanker.com ---
? Dietary Recommendations
SURGICAL MANAGEMENT OF
--- Content provided by FirstRanker.com ---
RENAL CALCULI
The primary goal of is to achieve maximal stone
--- Content provided by FirstRanker.com ---
clearance with minimal morbidity.Four minimal y invasive treatment modalities are
available: SWL, PNL, ureteroscopy, and
--- Content provided by FirstRanker.com ---
laparoscopic stone surgery.
Recent advancements in endoscopic technology and
--- Content provided by FirstRanker.com ---
surgical technique have dramatical y reduced theneed for open surgical procedures to treat patients
with renal and ureteral calculi.
--- Content provided by FirstRanker.com ---
About 80% to 85% patients can be treated with SWL.Factors associated with poor stone clearance rates:
1. large renal calculi (mean, 22.2 mm),
2. stones within dependent or obstructed portions of
--- Content provided by FirstRanker.com ---
the collecting system,3. stone composition (mostly calcium oxalate
monohydrate and brushite),
--- Content provided by FirstRanker.com ---
4. obesity or a body habitus that inhibits imaging,
5. unsatisfactory targeting of the stone.
Management of small stones
--- Content provided by FirstRanker.com ---
Most small urinary calculi wil pass spontaneously.
The presence of infection in an obstructed upper
--- Content provided by FirstRanker.com ---
urinary tract is dangerous and is an indication for
urgent surgical intervention.
Percutaneous nephrolithotomy
--- Content provided by FirstRanker.com ---
Placement of a hollow needle into the renal collecting
system through the soft tissue of the loin and the renal
--- Content provided by FirstRanker.com ---
parenchyma.the nephroscope is inserted through the track to visualise
the stone.
--- Content provided by FirstRanker.com ---
Small stones are grasped under vision and extracted.
Larger stones are fragmented and removed in pieces.
The aim is to remove all fragments if possible, and this
--- Content provided by FirstRanker.com ---
may take some time if the calculus is large.When the operation is over, a nephrostomy drain is left in
the system.
--- Content provided by FirstRanker.com ---
PCNL is sometimes combined with ESWL in the
treatment of stag-horn calculi.
--- Content provided by FirstRanker.com ---
Complications of PCNL include(1) haemorrhage from the punctured renal
parenchyma
--- Content provided by FirstRanker.com ---
(2) perforation of the collecting system(3) perforation of the colon or pleural cavity during
placement of the percutaneous track.
--- Content provided by FirstRanker.com ---
Extracorporeal shock wave
lithotripsy (ESWL)
--- Content provided by FirstRanker.com ---
A urinary calculus has a crystalline structure.Bombarded with shock waves of sufficient
energy it disintegrates into fragments.
--- Content provided by FirstRanker.com ---
As shock waves are poorly transmitted throughair, both the patient and the shock-wave
generators were immersed in a bath of water.
--- Content provided by FirstRanker.com ---
Modern ESWL machines do not have a water
bath .
--- Content provided by FirstRanker.com ---
The shocks are generated by piezoelectric cells.When ESWL is successful, the stone fragments must
pass down the ureter.
--- Content provided by FirstRanker.com ---
Ureteric colic is common after ESWL.The bulky fragments of a large stone may impact in the
ureter, causing obstruction.
--- Content provided by FirstRanker.com ---
To avoid this, a stent should be placed in the ureter sothat the kidney can drain while the pieces of stone pass.
Occasionally, impacted fragments have to be removed
--- Content provided by FirstRanker.com ---
ureteroscopically .
The principal complication of ESWL is infection.
--- Content provided by FirstRanker.com ---
Open surgery for renal calculiPyelolithotomy- indicated for stones in the renal
pelvis.
--- Content provided by FirstRanker.com ---
Extended pyelolithotomy
Nephrolithotomy
Partial nephrectomy
Nephrectomy
--- Content provided by FirstRanker.com ---
Treatment of bilateral renal stones
Usually the kidney with better function is treated
--- Content provided by FirstRanker.com ---
first unless the other kidney is more painful orthere is pyonephrosis, which needs urgent
decompression.
--- Content provided by FirstRanker.com ---
Silent bilateral staghorn calculi in the elderly and
infirm may be treated conservatively.
--- Content provided by FirstRanker.com ---
The patient should be encouraged to maintain ahigh fluid intake.
SURGICAL MANAGEMENT
--- Content provided by FirstRanker.com ---
OF URETERIC CALCULI
Indications for surgical removal of a
ureteric calculus
--- Content provided by FirstRanker.com ---
Repeated attacks of pain and the stone is not
moving
--- Content provided by FirstRanker.com ---
Stone is enlargingComplete obstruction of the kidney
Urine is infected
Stone is too large to pass
Stone is obstructing solitary kidney or there is
--- Content provided by FirstRanker.com ---
bilateral obstruction
Endoscopic stone removal
--- Content provided by FirstRanker.com ---
A ureteroscope is a long thin endoscope passedtransurethrally across the bladder into the ureter.
The ureteroscope is used to remove stones that
--- Content provided by FirstRanker.com ---
are impacted in the ureter.
Stones that cannot be caught in baskets or
--- Content provided by FirstRanker.com ---
endoscopic forceps under direct vision arefragmented by a lithotripter.
--- Content provided by FirstRanker.com ---
Push bangA stone in the middle or upper part of the ureter
is pushed back into the kidney using a ureteric
--- Content provided by FirstRanker.com ---
catheter.
Then ESWL.
Ureterolithotomy
--- Content provided by FirstRanker.com ---
BLADDER STONESA primary bladder stone is one that develops in
sterile urine; it often originates in the kidney.
--- Content provided by FirstRanker.com ---
A secondary stone occurs in the presence of
infection, outflow obstruction, impaired bladder
--- Content provided by FirstRanker.com ---
emptying or a foreign bodyMost vesical calculi are mixed.
Freely moves in the bladder.
--- Content provided by FirstRanker.com ---
Clinical featuresMen are affected eight times more frequently than women.
Stones may be asymptomatic and found incidentally.
Frequency is the earliest symptom.
--- Content provided by FirstRanker.com ---
Sensation of incomplete bladder emptying.Pain (strangury) - occurs at the end of micturition and is
referred to the tip of the penis or to the labia majora.
--- Content provided by FirstRanker.com ---
In children, screaming and pulling at the penis with the hand atthe end of micturition are indicative of bladder stone.
Haematuria
--- Content provided by FirstRanker.com ---
Interruption of the urinary stream is due to the stone blockingthe internal meatus.
Investigations
--- Content provided by FirstRanker.com ---
Examination of the urine reveals microscopichaematuria, pus or crystals.
ultrasound or plain radiogram.
--- Content provided by FirstRanker.com ---
Imaging of the whole of the urinary tract shouldbe undertaken to exclude an upper tract stone.
Treatment
--- Content provided by FirstRanker.com ---
The cause of the stone should be sought and
treated.
--- Content provided by FirstRanker.com ---
LitholapaxyOpen cystolithotomy