Download MBBS Surgery Presentations 63 Urolithasis Lecture Notes

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UROLITHIASIS

Dept of Surgery

A disease described in antiquity by many

observers.

Mentioned in Oath of Hippocrates.
Over last 150 years, pattern of stone disease has

changed .

Lower tract urate calculi stil a problem in the third

world.
Urolithiasis denotes stones originating anywhere

in the urinary tract, including the kidneys and

bladder.

NEPHROLITHIASIS.
URETEROLITHIASIS.
CYSTOLITHIASIS.

ETIOLOGY

Dietetic
Deficiency of vitamin A causes desquamation of

epithelium.

The cells form a nidus on which a stone is deposited.
Altered urinary solutes and col oids
Dehydration increases the concentration of urinary

solutes

Reduction of urinary colloids, which adsorb solutes, or

mucoproteins, which chelate calcium, might also result in

a tendency for crystal and stone formation.
Decreased urinary citrate
The presence of citrate in urine, 300?900 mg 24 h?1

as citric acid, tends to keep otherwise relatively

insoluble calcium phosphate and citrate in solution.

Renal infection
with urea-splitting streptococci, staphylococci and

especial yProteus spp.

Inadequate urinary drainage and urinary stasis
Stones are liable to form when urine does not pass

freely.

Prolonged immobilisation
Immobilisation from any cause results in skeletal

decalcification and an increase in urinary calcium.
HYPRECALCIURIA
Idiopathic hypercalciuria, Primary hyperparathyroidism,

Renal tubular acidosis, sarcoidosis and vitamin D

intoxication.

HYPREOXALURIA
Primary hyperoxaluria ,Enteric hyperoxaluria, Toxic

hyperoxaluria

HYPERURICOSURIA
Urinary Acidification and Alkalinization

Infection with urea splitting organisms.
The urea is split to ammonia, which is hydrolyzed to

ammonium hydroxide, raising urine pH to 8 to 9,

struvite precipitates.

Struvite stone disease has been cal ed "stone

cancer"

The stones tend to be very large (staghorn), and

frequently result in renal damage, but patients may

be relatively symptom free until the stone occupies

entire col ecting system.
Cystinuria
An inborn error of metabolism characterized by

increased urinary excretion ofcystine,ornithine,

lysine, arginine (COLA), due to a defect in renal

tubular reabsorption of these amino acids.

Cystine is insoluble and precipitates in

concentrated urine.

The stones are large ,radiolucent and recurrent.

Some drugs (triamterene, some of the older sulphas)

can be metabolized to insoluble compounds which

can precipitate in urine.

The carbonic anhydrase inhibitor, acetazolamide,

causes a combined Type 1 and Type 2 RTA which

may result in nephrolithiasis.


Types of renal calculus

Oxalate calculus

(calcium oxalate)

Irregular in shape.
Covered with sharp

projections, which cause

bleeding.

The surface of the

calculus is discoloured

by altered blood.

Is hard and radiodense.


Phosphate calculus
It is smooth and dirty white.
Tends to grow in alkaline urine,

especial y when urea-splitting

organisms are present.

It may enlarge to fil most of the

col ecting system, forming a

staghorn calculus.

Even a very large staghorn

calculus may be clinical y silent

for years.

Presents with haematuria,

urinary infection or renal failure.

Easy to see on radiographic

films.

Uric acid and urate

calculi

These are hard, smooth

and multiple.

They vary from yellow to

reddish brown,

multifaceted.

Are radiolucent and

appear on IVP as a filling

defect, which can be

mistaken for a tumour.

The presence of uric acid

stones is confirmed by CT.
Cystine calculus
Associated with a congenital error of metabolism that

leads to cystinuria.

Hexagonal, translucent, white crystals of cystine appear

only in acid urine.

They are multiple and may grow to form a cast of the

collecting system.

Pink or yellow when first removed, they change to a

greenish colour when exposed to air.

Cystine stones are radioopaque because they contain

sulphur, and they are very hard.

Xanthine calculus
Extremely rare.
Smooth and round, brick-red in colour, and show

lamellation on cross-section.


Clinical features

Silent calculus
UTI
Uraemia may be the first indication calculi.

Pain
MC symptom in 75% of

people.

Fixed renal pain is located

posteriorly in the renal

angle anteriorly in the

hypochondrium, or in both.

It may be worse on

movement, particularly on

climbing stairs.
Ureteric colic is an agonising pain passing from

the loin to the groin.

Typically, it starts suddenly causing the patient to

writhe to find comfort.

Pain resulting from renal stones rarely lasts more

than 8 hours in the absence of infection.

There is no pyrexia.
The severity of the colic is not related to the size

of the stone .

Haematuria
Sometimes a leading symptom of stone disease.
As a rule, the amount of bleeding is small.
Pyuria
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-

threatening septicaemia can quickly develop.

The mechanical effect of stones irritating the

urothelium may cause pyuria even in the absence of

infection.


Investigation

Radiography

The `KUB' film shows the

Opacities that may be

kidney, ureters and

confused with renal calculus

bladder.

Calcified mesenteric lymph

An opacity that maintains

node

its position relative to the

Gallstones or concretion in

urinary tract during

the appendix

respiration is likely to be a Tablets or foreign bodies in

calculus.

the alimentary canal

Phleboliths

Ossified tip of the 12th rib

Calcified tuberculous lesion

in the kidney

Calcified adrenal gland


Excretion urography

Also called IVP, is a radiological procedure used

to visualize abnormalities of the urinary system,

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

contrast media becomes visible on x-rays almost

immediately after injection.

X-rays are taken at specific time intervals to capture

the contrast as it travels through the different parts of

the urinary system.

This gives a comprehensive view of the patient's

anatomy and some information on the functioning of

the renal system.
An IVP can be performed in either emergency or

routine circumstances.

Emergency IVP
For patients who present to the A&E, with

severe renal colic and a positive hematuria test.

Patients with a positive find for kidney stones but with

no obstruction are usual y discharged with a follow-

up appointment with a urologist.

Patients with a kidney stone and obstruction are

usual y required to stay in hospital for monitoring or

further treatment.
Contraindications-IVP

Metformin should be to stoped 48 hours pre and

post procedure.

ARF/CRF.
Known allergy to contrast medium.

Contrast-enhanced computerised

tomography

CT has become the mainstay of investigation for

acute ureteric colic.

Ultrasound scanning
Ultrasound scanning is of most value in locating

stones for treatment by extracorporeal shock

wave lithotripsy (ESWL).


Ureteric calculus

URETERIC CALCULUS

A stone in the ureter usually comes from the kidney.
Most are single small stones that are passed spontaneously.
Clinical features

Ureteric colic
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

anterior surface of the thigh.

When the stone is in the intramural ureter, the pain can be

referred to the tip of the penis.

Strangury, the painful passage of a few drops of urine,

typically occurs with the stone in the intramural part of the

ureter.
Haematuria

Almost every attack of ureteric colic is associated

with microscopic haematuria, which lasts for a

day or so.

More profuse bleeding is uncommon and should

raise the suspicion that the colic is due to

passage of a clot.

When the stone becomes impacted, the attacks of

colic give way to a more consistent dull pain, often

felt in the iliac fossa.

The pain may be increased by exercise and lessened

by rest.

Severe renal pain subsiding after a day or so

suggests complete ureteric obstruction.

If obstruction persists after 1?2 weeks, the calculus

should be removed because prolonged distension of

the kidney wil eventual y lead to atrophy of the renal

parenchyma.


Impaction

There are five sites of

narrowing where the

stone may be arrested

What are those?

Abdominal examination

Tenderness and some rigidity over some part of the

course of the ureter.

On the right side is to distinguish from ??
The presence of haematuria does not rule out

appendicitis, because an inflamed appendix can give

rise to a local ureteritis.
Imaging

Plain abdominal radiograph.
Intravenous urography.
Spiral CT scan.
Cystoscopy.

CONSERVATIVE

MANAGEMENT

Mainstay is the forced increase in fluid intake

to achieve a daily urine output of 2 liters .

Increased urine output has two effects-
1. Mechanical diuresis
2. The dilute urine alters the supersaturation of

stone components.

? Dietary Recommendations


SURGICAL MANAGEMENT OF

RENAL CALCULI

The primary goal of is to achieve maximal stone

clearance with minimal morbidity.

Four minimal y invasive treatment modalities are

available: SWL, PNL, ureteroscopy, and

laparoscopic stone surgery.

Recent advancements in endoscopic technology and

surgical technique have dramatical y reduced the

need for open surgical procedures to treat patients

with renal and ureteral calculi.
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

the collecting system,

3. stone composition (mostly calcium oxalate

monohydrate and brushite),

4. obesity or a body habitus that inhibits imaging,
5. unsatisfactory targeting of the stone.

Management of small stones
Most small urinary calculi wil pass spontaneously

.

The presence of infection in an obstructed upper

urinary tract is dangerous and is an indication for

urgent surgical intervention.
Percutaneous nephrolithotomy

Placement of a hollow needle into the renal collecting

system through the soft tissue of the loin and the renal

parenchyma.

the nephroscope is inserted through the track to visualise

the stone.

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

may take some time if the calculus is large.

When the operation is over, a nephrostomy drain is left in

the system.

PCNL is sometimes combined with ESWL in the

treatment of stag-horn calculi.

Complications of PCNL include
(1) haemorrhage from the punctured renal

parenchyma

(2) perforation of the collecting system
(3) perforation of the colon or pleural cavity during

placement of the percutaneous track.


Extracorporeal shock wave

lithotripsy (ESWL)

A urinary calculus has a crystalline structure.
Bombarded with shock waves of sufficient

energy it disintegrates into fragments.

As shock waves are poorly transmitted through

air, both the patient and the shock-wave

generators were immersed in a bath of water.

Modern ESWL machines do not have a water

bath .

The shocks are generated by piezoelectric cells.
When ESWL is successful, the stone fragments must

pass down the ureter.

Ureteric colic is common after ESWL.
The bulky fragments of a large stone may impact in the

ureter, causing obstruction.

To avoid this, a stent should be placed in the ureter so

that the kidney can drain while the pieces of stone pass.

Occasionally, impacted fragments have to be removed

ureteroscopically .

The principal complication of ESWL is infection.

Open surgery for renal calculi

Pyelolithotomy- indicated for stones in the renal

pelvis.

Extended pyelolithotomy
Nephrolithotomy
Partial nephrectomy
Nephrectomy


Treatment of bilateral renal stones
Usually the kidney with better function is treated

first unless the other kidney is more painful or

there is pyonephrosis, which needs urgent

decompression.

Silent bilateral staghorn calculi in the elderly and

infirm may be treated conservatively.

The patient should be encouraged to maintain a

high fluid intake.

SURGICAL MANAGEMENT

OF URETERIC CALCULI
Indications for surgical removal of a

ureteric calculus

Repeated attacks of pain and the stone is not

moving

Stone is enlarging
Complete obstruction of the kidney
Urine is infected
Stone is too large to pass
Stone is obstructing solitary kidney or there is

bilateral obstruction

Endoscopic stone removal

A ureteroscope is a long thin endoscope passed

transurethrally across the bladder into the ureter.

The ureteroscope is used to remove stones that

are impacted in the ureter.

Stones that cannot be caught in baskets or

endoscopic forceps under direct vision are

fragmented by a lithotripter.


Push bang

A stone in the middle or upper part of the ureter

is pushed back into the kidney using a ureteric

catheter.

Then ESWL.
Ureterolithotomy
BLADDER STONES

A primary bladder stone is one that develops in

sterile urine; it often originates in the kidney.

A secondary stone occurs in the presence of

infection, outflow obstruction, impaired bladder

emptying or a foreign body

Most vesical calculi are mixed.
Freely moves in the bladder.

Clinical features

Men are affected eight times more frequently than women.
Stones may be asymptomatic and found incidentally.
Frequency is the earliest symptom.
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.

In children, screaming and pulling at the penis with the hand at

the end of micturition are indicative of bladder stone.

Haematuria
Interruption of the urinary stream is due to the stone blocking

the internal meatus.
Investigations

Examination of the urine reveals microscopic

haematuria, pus or crystals.

ultrasound or plain radiogram.
Imaging of the whole of the urinary tract should

be undertaken to exclude an upper tract stone.

Treatment

The cause of the stone should be sought and

treated.

Litholapaxy
Open cystolithotomy

This post was last modified on 08 April 2022