Transcript UROLITHIASIS

UROLITHIASIS
BACKGROUND
 Urinary stone disease continues to occupy an
important place in everyday urological practice.
The average lifetime risk of stone formation has
been reported in the range of 5-10%.
 A predominance of men over women (approx.
3:1) can be observed with an incidence peak
between the fourth and fifth decade of life.
 Recurrent stone formation is a common
problem with all types of stones and therefore an
important part of the medical care of patients
with stone disease.
Theories of Stone Formation
 A. Nucleation Theory
 B. Stone Matrix Theory
 C. Inhibitor of Crystallization
Theory
Most investigators acknowledge
that these 3 theories describe the
3 basic factors influencing urinary
stone formation. It is likely that
more than one factor operates in
causing stone disease. A
generalized model of stone
formation combining these 3 basic
theories has been proposed.
RISK FACTORS
•Start of disease early in life: <25 years
•Stone containing brushite
•Only one functioning kidney
•Disease associated with stone formation:
- hyperparathyroidism
- renal tubular acidosis (partial/complete)
- jejunoileal bypass
- Crohn’s disease
- intestinal resection
- malabsorptive conditions
- sarcoidosis
- hyperthyroidism
RISK FACTORS
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Medication associated with stone formation:
- calcium supplements
- vitamin D supplements
- acetazolamide - ascorbic acid in megadoses ( > 4 g/day)
- sulphonamides - triamterene
- indinavir
•Anatomical abnormalities associated with stone formation:
- tubular ectasia (medullary sponge kidney)
- pelvo-ureteral junction obstruction
- calix diverticulum, calix cyst
- ureteral stricture
- vesico-ureteral reflux
- horseshoe kidney
- ureterocele
Etiology (according Capital and I. Pogo Elko).
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A). Disorders of urinary tract:
congenital abnormalities those favor to
apostasies;
obstructive processes;
neurogenic duskiness of the urinary tract;
inflammative and parasitogenic damages;
foreign bodies of urinary tract;
traumatic injuries.
B) Liver and digestive tract disorders:
latent and manifested hepathopathiy;
hepatogenic gastritis;
colitis, etc.
C) Endocrine diseases
hyperparathyreoidism;
hyperthyroidism;
hypopituitaric diseases;
D.) Infect focuses of the urogenital system.
E) Metabolism disorders.
essential hypercalciuria;
disorders of membranes for colloid
substances diffusion;
renal rickets, etc
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F) Injuries those leads to continuous
immobilization
fractures of the vertebral column and limbs
osteomyelitis
diseases of the bones and joints
chronic diseases of the visceral organs and
nervous system.
G) Climate and geographical causes.
dry and hot climate with a high vaporization
decrease water supply
iodine deficiency
H) Disorders of nutrition and vitamins
balance:
retinole and oscorbine acid deficiency in
food.
Excessive amount of the ergocalciferole in
organism.
Renal Calculi
 1 Coral calculus
 2 Coral calculi fragment
 3 Calculi, which are impregnated with blood pigments
Diagnostic imaging
Medical History
 A personal as well as a
family history should be
obtained for all patients.
 A history of inflammatory
bowel disease, recurrent
urinary tract infection,
prolonged periods of
immobilization, gout, or
familial occurrence of
certain inherited renal
diseases, eg, renal tubular
acidosis or cystinuria,
should be sought.
Clinical Manifestations
 Acute obstruction of
the urinary tract may
cause renal colic, a
form of severe
abdominal pain often
accompanied by
nausea and vomiting
due to celiac ganglion
stimulation. Onset is
sudden, often during
the night or in the
early morning
Clinical Manifestations
 Obstructing calculi in the upper urinary
tract cause an extreme crescendo like
pain in the flank that generally radiates
laterally around the abdomen to the
corresponding groin and testicles in
males and labia major in females.
 When the stone obstructs the
midureter, the pain tends to radiate to
the lateral flank and abdominal region.
 However, when the obstruction is in the
distal ureter (near the ureterovesical
junction), the patient exhibits symptoms
of bladder irritation (frequency and
urgency or genital pain).
Clinical Manifestations
 Fever is rarely present except when a urinary tract
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infection accompanies obstruction.
Pulse rate and blood pressure, however, may be
elevated as a result of the pain and agitation caused by
the renal colic.
The patient's abdomen is generally flat and soft, with
moderate deep tenderness on palpation where the
calculus is lodged.
Some patients also have extensive hyperesthesia of the
abdominal wall, either anteriorly or posteriorly.
The costo-vertebral area may be tender to percussion.
Laboratry Investigations
 Stone analysis:
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In every patient one stone should
be analysed.
 Blood analysis:
Calcium Albumin Creatinine Urate
 Urinalysis:
Fasting morning spot urine sample
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Dip-stick test: pH, Leucocytes/Bacteria
Cystine test, Ca, P, citrate, urate
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Urinalysis.
 This test usually reveals
either gross or microscopic
hematuria. Although hematuria
may be absent in complete
obstruction, microhematuria
may be present in
symptomatic partial
obstruction.
 Pyuria, usually moderate, may
accompany obstruction even
in the absence of identifiable
infecting organisms. If severe
pyuria is present, infection
should be considered
(especially in a female), since
the stones may be secondary
to infection.
Diagnostic imaging
Routine examination involves a plain abdominal film of the
kidneys, ureters and bladder (KUB) At least 90% of all
renal stones are radiopaque and therefore readily visible
on a plain film of the abdomen
Diagnostic imaging
Excretory pyelography must
not be carried out in the
following patients - those:
 With an allergy to
contrast media
 With S-creatinine level >
200 µmol/L
 On medication with
metformin
 With myelomatosis
Diagnostic imaging
Special examinations that
can be carried out
include:
 Retrograde or antegrade
pyelography
 Retrograde pneumopyelography or
cystography
 Spiral (helical)
unenhanced computed
tomography (CT)
 Scintigraphy.
Diagnostic imaging
UltrasonographyIn patients in whom it is not
possible to obtain an
intravenous urogram,
ultrasonic evaluation of the
kidneys may aid in the
diagnosis of renal stones.
In pregnant women with
flank pain in whom it is
desirable to limit radiation
exposure or in anuric
patients or patients with
chronic renal failure, the
presence of hydronephrosis
on acoustic shadowing may
be diagnostic.
Diagnostic imaging
 Cystoscopia shows swallowing of the ureter
orifice in lower location of the stone, it may
also partially project out to the orifice.
Cystoscopy
TREATMENT
 Conservative
 Instrumental
 Surgical
Pain relief
Pain relief involves the administration
by various routes of the following
agents:
 Diclofenac sodium
 Indomethacin
 Hydromorphone hydrochloride +
atropine sulphate
 Baralgin
 No-spae + Analgine
 Tramadol
Pain relief
 Warm bath
 Spasmolytic “cocktails” (with papaverine, spasmalgone,
no-spanum, promedole) should be taken.
 A high dosage of the cystenal or urolesan (20 drops on
the piece of sugar) is rather effective at the start of the
renal colic.
 If ache doesn’t disappear the novocaine blockade of the
spermatic cord in males and round ligament in females is
required.
 Physical method.
Pain relief
 For patients with ureteral
stones that are expected to
pass spontaneously,
suppositories or tablets of
diclofenac sodium, 50 mg
administered twice daily
over 3-10 days, might be
useful in reducing ureteral
oedema and the risk of
recurrent pain. The patient
should be instructed to
sieve the urine in order to
retrieve a concrement for
analysis.
Pain relief
 When pain relief
cannot be obtained
by medical means,
drainage by stenting
or percutaneous
nephrostomy (PN) or
stone removal
should be carried
out.
Stone removal
The size, site and shape of the stone at the initial
presentation influence the decision to remove the
stone. Also, the likelihood of spontaneous
passage has to be evaluated. Spontaneous stone
passage can be expected in up to 80% of patients
with stones not larger than 4 mm in diameter. For
stones with a diameter exceeding 7 mm the
chance of spontaneous passage is very low.
The overall passage rate of ureteral stones is:
 Proximal ureteral stones: 25%
 Mid-ureteral stones: 45%
 Distal ureteral stones: 70%
Indications for Active Stone removal
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Stone removal is usually indicated
for stones with a diameter
exceeding 6-7 mm. Active stone
removal is strongly recommended
in patients fulfilling the following
criteria:
Persistent pain despite adequate
medication
Persistent obstruction with risk of
impaired renal function
Stone with urinary tract infection
Risk of pyonephrosis or urosepsis
Bilateral obstruction.
Obstructing calculus in a solitary
functioning kidney
Stone removal
 A test for bacteriuria should be carried out in all
patients in whom stone removal is planned. Screening
with dipsticks might be sufficient in uncomplicated
cases. In others, urine culture is necessary. In all
patients with a positive test for bacteriuria, with a
positive urine culture or when there is suspicion of an
infective component, treatment with antibiotics should
be started before the stone-removing procedure.
 Bleeding disorders and anticoagulation treatment
should be considered. These patients should be
referred to an internist for appropriate therapeutic
measures during the stone-removing procedure.
Treatment with salicylates should be stopped 10 days
before the planned stone removal.
Indications to surgical operation
 Frequent attacks of the renal colic or persistent pain that
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disables the patient.
Disorder of the urine outflow causing the hydronephrotic
degeneration of the kidney.
Obturative anuria.
Frequent attacks of the acute pyelonephritis, progress of
the chronic pyelonephritis that causes renal insufficiency.
Total hematuria.
Calculous pyonephrosis, apostematous pyelonephritis or
carbuncle of the kidney.
Stone at the sole kidney that causes obstruction.
Stone in the ureter of the sole kidney that won’t pass
away spontaneously.
Stone removal
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In patients with coagulation disorders the
following treatments are contra-indicated:
extracorporeal shock wave lithotripsy
(ESWL), percutaneous nephrolithotomy
with or without lithotripsy (PNL),
ureteroscopy (URS) and open surgery.
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In pregnant women, ESWL, PNL and URS
are contra-indicated. In expert hands URS
has been successfully used to remove
ureteral stones during pregnancy, but it
must be emphasized that complications
of this procedure might be difficult to
manage.
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In such women, the preferred treatment
is drainage, either with a percutanous
nephrostomy catheter, a double - J stent
or a ureteral catheter .
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For patients with a pacemaker it is wise
to consult a cardiologist before
undertaking an ESWL treatment.
Percutaneous Procedures
 Percutaneous nephrostomy.
Because of this technique,
urologists can now perform
operative procedures within the
kidney without using the standard
large flank incisions and
mobilization of the kidney.
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This technique, along with
refinements in endoscopic
instruments and advances in
fiberoptics, allows endoscopic
manipulation in the upper urinary
tract by the percutaneous
approach.
 Percutaneous
nephrolithotomy with or
without lithotripsy (PNL)
Closed Surgical Procedures
 Cystoscopic technique
[With the patient under anesthesia
and with fluoroscopic control,
stones in the distal ureter can
sometimes be removed with a
wire stone basket]
 Ureteropyeloscopy
[Manipulation of small ureteral
stones under direct vision with a
ureteroscope is a major advance
in the management of ureteral
calculi. With this technique, small
stones can be easily trapped in a
stone basket and safely extracted
through the dilated ureter.
Extracorporeal Shock Wave Lithotripsy
 An extracorporeal noninvasive
technique that uses shock waves
to disintegrate urinary calculi while
the patient is immersed in a water
bath has been tested extensively
and is now in clinical use. With
this technique, calculi in the upper
urinary tract are reduced to
fragments, which pass
spontaneously from the collecting
system and bladder in most
patients.
 Size, location, and consistency of
stone determine the number of
shocks needed for fragmentation.
In general, between 500 and
2,000 shocks arc necessary to
fragment and pulverize an
intrarenal calculus sufficiently for
complete passage.
Open Surgical Procedures
 Pyelolithotomy: Simple
pyelolithotomy is used for
removal of calculi
confined to the renal
pelvis. Minimal dissection
of the renal sinus is
usually needed, and
exposure of the entire
kidney is not required.
This procedure is not
indicated for the removal
of entrapped caliceal
stones or large, branched
renal calculi.
Open Surgical Procedures
 Ureterolithotomy. There are
retroperitoneal,
transperitoneal and
combined surgical
accesses. It depends on
stone location. To remove
stone from the superior
ureter the Fedorov’s access
is used, from medial ureter
– Cuckulidze’s or
Derev’yanko access is
performed, the inferior
ureter – Pyrogov’s access
is needed, the pelvic portion
of ureter may be accessed
through the suprapubic
arcuate incision.
Open Surgical Procedures
Nephrectomy
Nephrolithotomy
Cystolithotomy
Preventive treatment in calcium stone
disease
Preventive treatment in patients with calcium stone
disease should be started with conservative
measures. Pharmacological treatment should be
instituted only when the conservative regimen
fails. Patients should be encouraged to have a
high fluid intake. This advice is valid irrespective
of stone composition. For a normal adult, the 24-h
urine volume should exceed 2000 ml, but the
supersaturation level should be used as a guide to
the necessary degree of urine dilution. The fluid
intake should be evenly distributed over the 24-h
period, and particular attention should be paid to
situations where an unusual loss of fluid occurs.
Preventive treatment in calcium stone
disease
Diet should be of a 'common sense' type - a mixed balanced
diet with contributions from all food groups but without
excesses of any kind. The intake of fruits and vegetables
should be encouraged because of the beneficial effects of
fibre. Care must be taken, however, to avoid fruits and
vegetables that are rich in oxalate. Wheat bran is rich in
oxalate and should be avoided. In order to avoid an
oxalate load, the excessive intake of products rich in
oxalate should be limited or avoided. This is of particular
importance in patients in whom high excretion of oxalate
has been demonstrated. The following products have a
high content of oxalate :
 Rhubarb 530 mg oxalate/100 g
 Spinach 570 mg oxalate/100 g
 Cocoa 625 mg oxalate/100 g
 Tea leaves 375-1450 mg oxalate/100 g
 Nuts 200-600 mg oxalate/100 g.
Preventive treatment in calcium stone
disease
Vitamin C in doses up to 4 g/day can be taken
without increasing the risk of stone formation.
Animal protein should not be ingested in
excessive amounts. It is recommended that the
animal protein intake is limited to approximately
150 g/day. Calcium intake should not be restricted
unless there are very strong reasons for such
advice. The minimum daily requirement for
calcium is 800 mg and the general
recommendation is 1000 mg/day. Supplements of
calcium are not recommended except in cases of
enteric hyperoxaluria, in which additional calcium
should be ingested with meals.
Preventive treatment in calcium stone
disease
The intake of foodstuffs particularly rich in urate
should be restricted in patients with
hyperuricosuric calcium oxalate stone disease , as
well as in patients with uric acid stone disease.
The intake of urate should not be more than 500
mg/day. Below are examples of food rich in urate :
 Calf thymus 900 mg urate/100 g
 Liver 260-360 mg urate/100 g
 Kidneys 210-255 mg urate/100 g
 Poultry skin 300 mg urate/100 g
 Herring with skin, sardines, anchovies, sprats 260500 mg urate/100 g.
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