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

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

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

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

Stone Formation Nucleation Metastable Undersaturation Ion Conc in Soln

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%

Oxalate Stone

Phosphate Stone

Uric Acid Stone

Cystine Stone

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

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

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

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

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

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

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

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)

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

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)

Percutaneous Nephrolithotomy (PCNL)

Extracorporeal Shockwave Lithotripsy (ESWL)

ESWL

Bilateral Staghorn Calculi

Effect of a Staghorn Calculus

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

Upper ureteric stone

Lower ureteric stone

Ureteric stone - Ureteroscopy

Ureteric Stone - Basketing

Lower Ureteric Stone

Lower Ureteric Stone in Basket

Bladder Stones - x-ray

Bladder Stones - endoscopy

Bladder Stone - Lithalopaxy

Bladder Stone - Lithotripsy

Urethral Calculus

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)

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