1. UROLITHIASIS Dr Zakir Hussain Rajpar Assistant Professor Of Urology
Liaquat University Of Medical And Health Sciences

2. 2
Urolithiasis
Urolithiasis (from Greek oûron-urine and lithos-stone) is the condition where urinary stones are formed or located anywhere in the urinary system. 2

3. Background

4. Urolithiasis Kidney stones Ureteral stones Bladder stones4
Urolithiasis
Kidney stones
Ureteral stones
Bladder stones
Urethral stones 4

5. 5 5

6. Background
Urolithiasis is a common disease that is estimated to produce medical costs of $2.1 billion per year in the United States alone.
Urolithiasis has been a part of the human condition for millennia and have even been found in Egyptian mummies.

7. Background
Renal colic affects approximately 1.2 million people each year in USA and accounts for approximately 1% of all hospital admissions.
Most active emergency departments (EDs) manage patients with acute renal colic every day

8. Epidemiology

9. Epidemiology Urolithiasis occurs in all parts of the world
A lifetime risk:
2-5% for Asia
8-15% for the West
Hot Climate
Dietary habits
Hereditary factors

10. Epidemiology
The lower the economic status, the lower the likelihood of renal stones
Most at years
Peak incidence at years
Male-to-female ratio of 3:1

11. Chemical types and etiology

12. Chemical Types Four main chemical types: Calcium stones
Struvite (magnesium ammonium phosphate) stones
Uric acid stones
Cystine stones

13. Calcium stones Calcium stones account for 75% of Urolithiasis.
Radio-opaque
Multiple factors and etiologies
Mostly incidental

14. Calcium Stone Known etiologies
Incidental
Hyperparathyroidism
Increased gut absorption of calcium
Renal calcium leak
Renal phosphate leak
Hperuricosuria
Hperoxaluria
Hypocitraturia
Hypomagnesuria

15. Calcium Stone

16. Struvite (magnesium ammonium phosphate) stones
Account for 15% of renal calculi
Infectous stones
Gram-negative rods capable of splitting urea into ammonium, which combines with phosphate and magnesium
More common in females
Urine pH is typically greater than 7

17. Stag horn stones are non obstructive thus painless
1717
Struvite (magnesium ammonium phosphate) stones
Stag horn stones are non obstructive thus painless
Slowly growing
Discovered incidentally 17

18. Uric acid stones Account for 6% of renal calculi
Urine pH less than 5.5
High purine intake eg.
organ meats
legumes
malignancy
25% of patients have gout

19. Uric Acid Stones

20. Uric Acid Stones

21. Cystine stones 2% of renal calculi Autosomal recessive trait
Intrinsic metabolic defect resulting in failure of renal tubular reabsorption of:
Cystine
Ornithine
Lysine
Arginine
Urine becomes supersaturated with cystine, with resultant crystal deposition

22. Cystine Stones
Radio-faint

23. History

24. History The presentation is variable.
Patients with urinary calculi may report
Pain
Infection
Hematuria
Asymptomatic

25. Silent Kidney stones
Small nonobstructing stones in the kidneys only occasionally cause symptoms.
If present, symptoms are usually moderate and easily controlled.

26. Obstructive ureteral stone
The passage of stones into the ureter is associated with classic renal colic because of:
subsequent acute obstruction
proximal urinary tract dilation
ureteral spasm
Acute renal colic is probably the most excruciatingly painful event a person can endure

27. Classic Renal Colic
Acute onset of severe flank pain radiating to the groin
Gross or microscopic hematuria
Nausea, and vomiting not associated with an acute abdomen in 50%

28. Staghorn stone Staghorn calculi are often relatively asymptomatic.
Branched kidney stone occupying the renal pelvis and at least one calyceal system.
Manifest as infection and hematuria.

29. Acute renal failure Asymptomatic bilateral obstruction
Solitary Kidney with obstructive stone

30. Location and characteristics of pain from ureteral stones
Depends on the level of obstruction and its degree:
ureteropelvic junction
pelvic brim
ureterovesical junction

31. UPJ Stone
Stones obstructing the ureteropelvic junction may present with mild-to-severe deep flank pain without radiation to the groin

32. Ureteral Stone
Cause abrupt, severe, colicky pain in the flank and ipsilateral lower abdomen
with radiation to the testicles or the vulvar area.
Intense nausea, with or without vomiting, usually is present.

33. Upper ureter
Tends to radiate to the flank and lumbar areas

34. Mid Ureter Cause pain that radiates anteriorly and caudally.
Can easily mimic appendicitis on the right or acute diverticulitis on the left.

35. Distal Ureter and UVJ stones
Cause pain that tends to radiate into the groin or testicle in the male or labia majora in the female
At the ureterovesical junction also may cause irritative voiding symptoms mimicking cystitis, such as:
urinary frequency
dysuria

36. Pain distribution review

37. Bladder Stones
Usually asymptomatic and are passed relatively easily during urination.
Rarely, a patient reports positional urinary retention (obstruction precipitated by standing, relieved by recumbency).

38. Phases of an attack

39. Phases of an attack The entire process typical lasts 3-18 hours
Acute phase: peak in most patients within 2 hours of onset (30 min to 6 hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase hours

40. Physical exam

41. Physical exam Dramatic costovertebral angle tenderness
unremarkable abdominal evaluation
painful testicles but normal-appearing
constant body positional movements (eg, writhing, pacing)
Tachycardia
Hypertension
Microscopic hematuria

42. Diagnosis

43. Diagnosis
The diagnosis of nephrolithiasis is often made on the basis of clinical symptoms alone, although confirmatory tests are usually performed.

44. Laboratory tests

45. Labarotary Testing The recommended based on EUA recommendations:
Urinary sediment/dipstick test: To demonstrate blood cells
Serum creatinine level: To measure renal function

46. Additional Lab Tests May be helpful: CBC in febrile patients
Serum electrolyte assessment in vomiting patients
24-Hour urine profile on outpatient basis

47. Imaging studies

48. Imaging studies
Noncontrast abdominopelvic CT scan: The imaging modality of choice for assessment of urinary tract disease, especially acute renal colic.
IV contrast and delayed images might be required in selected cases

49. Imaging studies Renal ultrasonography:
Renal stone
Hydronephrosis or ureteral dilation
Misses 30 % of stones
Plain abdominal radiograph (flat plate or KUB) misses 40 % of stones

50. Imaging studies IVP (urography) historically, the criterion standard
In rare select situations:
Plain renal tomography
Retrograde pyelography
Nuclear renal scanning

51. Management

52. Emergency Renal Colic IV access to allow : In case of infection: Fluid
Analgesics:
Paracetamol
NSAID
Opiod
Antiemetic
In case of infection:
Urine culture
Blood culture accordingly e.g. febrile
Antibiotics

53. Approach Considerations
In emergency settings what should be kept in mind is the small percentage suffering renal damage or sepsis.
These include:
Evident infection with obstruction
A solitary functional kidney
Bilateral ureteral obstruction
Renal failure

54. Important
The most morbid and potentially dangerous aspect of stone disease is the combination of urinary tract obstruction and upper urinary tract infection.
Pyelonephritis
Pyonephrosis
Urosepsis
Early recognition and immediate surgical drainage are necessary in these situations

55. Approach Considerations
The size of the stone is an important predictor of spontaneous passage.
A stone less than 4 mm in diameter has an 80% chance of spontaneous passage; this falls to 20% for stones larger than 8 mm in diameter

56. Approach Considerations
Hospital admission is clearly necessary when any of the following is present:
􀁺 Oral analgesics are insufficient to manage the pain.
􀁺Intractable vommiting
􀁺 Ureteral obstruction from a stone occurs in a solitary or transplanted kidney.
􀁺Bilateral ureteral obstruction
􀁺 Ureteral obstruction from a stone occurs in the presence of
a urinary tract infection (UTI)
Fever
Sepsis
Pyonephrosis

57. Approach Considerations
Relative indications to consider for a possible admission include comorbid conditions
diabetes
dehydration
renal failure
immunocompromised state
perinephric urine extravasation
pregnancy

58. Clinic Follow up
Patients who do not meet admission criteria to be discharged on medical expulsive therapy from the ED in anticipation that the stone will pass spontaneously at home.
Arrangements should be made for follow-up with a urologist in 2-3 days.

59. Active medical expulsive therapy
Paracetamol PRN for pain with or without Codeine
NSAID PRN for pain
Oral opiod analogue for severe pain
Alpha blockers
Antiemetic PRN for nausea and/or vommiting
Prednisone 20 mg twice daily for 6 days
With MET, stones 5-8 mm in size often pass, especially if located in the distal ureter.

60. Approach Considerations
General recommendation not to wait longer than 4 weeks for a stone to pass spontaneously before considering intervention.

61. Approach Considerations
About 15-20% of patients require invasive intervention eventually as emergency or electively due to:
stone size
continued obstruction
Infection
intractable pain

62. Indications for Surgery
The primary indications for surgical treatment include:
Pain
Infection
Obstruction
Indications for urgent intervention:
Obstruction complicated by evident infection
Obstruction complicated by acute renal failure
Solitary kidney
Bilateral obstruction

63. Surgical options Obstruction relief: Definitive surgical treatment:
Ureteral stent insertion
Percutaneous nephrostomy
Definitive surgical treatment:
ESWL
Ureteroscopy
PCNL
Open, laparoscopic and robotic pyelo-lithotomy, ureterolithotomy, cystolithotomy
Open anatrophic nephrolithotomy

64. Surgical options
For an obstructed and infected collecting system secondary to stone disease
Emergency surgical relief is required with no contraindications:
percutaneous nephrostomy for critical patients
ureteral stent placement for stable patients

65. Surgical options
The vast majority of symptomatic urinary tract calculi are now treated with noninvasive or minimally invasive techniques
Open surgical excision of a stone from the urinary tract is now limited to isolated atypical cases

66. Surgical options
ESWL and ureteroscopy are internationaly recognized as first-line treatments for ureteral stones.
The 2005 American Urological Association (AUA) staghorn calculus guidelines recommend percutaneous nephrostolithotomy as the cornerstone for management

67. Ureteral Stent
Guarantees drainage of urine from the kidney into the bladder and bypass any obstruction.
Relieves renal colic pain even if the actual stone remains.
Dilate the ureter, making ureteroscopy and other endoscopic surgical procedures easier to perform later.

68. Percutaneous nephrostomy
Indicated if stent placement is inadvisable or impossible.
In particular patients with pyonephrosis who have a UTI or urosepsis exacerbated by an obstructing calculus

69. Extracorporeal shockwave lithotripsy
ESWL, the least invasive of the surgical methods of stone removal
Utilizes an underwater energy wave focused on the stone to shatter it into passable fragments
It is especially suitable for stones that are smaller than 2 cm and lodged in
the upper or middle calyx
the upper ureter

70. Extracorporeal shockwave lithotripsy
The patient, under varying degrees of anesthesia
The shock head delivers shockwaves developed from an
Electrohydraulic
Electromagnetic
piezoelectric source

71. Ureteroscopy
Ureteroscopic manipulation of a stone is a commonly applied method of stone removal
A small endoscope, which may be
Rigid
Semirigid
Flexible
is passed into the bladder and up the ureter to directly visualize the stone

72. Ureteroscopy
Flexible ureteroscopy allows tackling of even lower calyceal stones
Stones are fragmented using
Swiss lithoclast
Laser
Ultrasonic lithotripter
Stones are retrieved using a stone basket

73. Percutaneous nephrostolithotomy
Percutaneous procedures are generally reserved for large and/or complex renal stones and failures from the other 2 modalities
Percutaneous nephrostolithotomy is especially useful for stones larger than 2 cm in diameter

74. Percutaneous nephrostolithotomy
In some cases, a combination of SWL and a percutaneous technique is necessary to completely remove all stone material from a kidney.

75. Open Surgery
Open surgery has been used less and less often since the development of the previously mentioned techniques
It now constitutes less than 1% of all interventions.
Disadvantages include
longer hospitalization
increased requirements for blood transfusion.

76. Long-Term Monitoring
Metabolic evaluation is done by a typical 24-hour urine determination of:
urinary volume pH
specific gravity
Calcium
Citrate
Magnesium
Oxalate
Phosphate
uric acid.

77. Long-Term Monitoring Most common findings are Hypercalciuria
Hyperuricosuria
Hyperoxaluria
Hypocitraturia
low urinary volume

78. Chemoprophylaxis
Chemoprophylaxis of uric acid and cystine calculi consists primarily of long-term alkalinization of urine.

79. Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in patients with pure uric acid stones, allopurinol (300 mg qd) is recommended

80. Chemoprophylaxis
Pharmaceuticals that can bind free cystine in the urine:
D-penicillamine
2-alpha-mercaptopropionyl-glycine
Help reduce stone formation in cystinuria.
Captopril has been shown to be effective in some trials

81. Dietary Measures
In almost all patients in whom stones form, an increase in fluid intake and, therefore, an increase in urine output is recommended.
This is likely the single most important aspect of stone prophylaxis
The goal is a total urine volume in 24 hours in excess of 2 liters.

82. Dietary Measures
The only other general dietary guidelines are to avoid excessive salt and protein intake.
Moderation of calcium and oxalate intake is also reasonable
Beware to advice moderation not avoid calcium intake as it will result in calcium deficiency disorders, most importantly osteoperosis.

83. Thank you

84. References Main references:
Medscape article nephrolithiasis by J Stuart Wolf Jr, MD, FACS updated feb 11, 2013
Campbell-Walsh Urology 10th edition
Smith and Tanagho's General Urology, Eighteenth Edition
Images used in this presentation are from different web based resources
N.B. The presentation is directed to general medical audience in the hospital mainly nurses and physicians with special focus on the acute management.