RENAL AND UROLOGY

Urolithiasis
Ben Thomas James Hall

Causes of urolithiasis
Renal and ureteric calculi Idiopathic Dietary factors (e.g. low intake of fluid, high intake of purine) Gouty diathesis Metabolic anomalies (e.g. hyperparathyroidism) Heredity (e.g. cystinuria, xanthinuria) Urinary stasis: congenital (e.g. obstruction of the pelviureteric junction, horseshoe kidney) or stricture Chronic infection (urease-producing organisms (e.g. Proteus) may lead to magnesium ammonium phosphate staghorn calculi in the renal pelvis) Foreign bodies (ureteric stents, suture material) Diseased tissue (e.g. tuberculosis) Prolonged immobility (e.g. spinal injury, spina bifida) Vesical calculi Voiding dysfunction (e.g. urethral stricture, benign prostatic hyperplasia, stenosis of the bladder neck) Foreign bodies (long-term urethral/suprapubic catheterization, ureteric stents) Reconstructed bladder (enterocystoplasty/bladder substitution) Detrusor failure 1

Urolithiasis is the presence of one or more calculi at any location within the urinary tract. The disease affects 15% of the population in developed nations with a peak incidence between 20 and 50 years of age. Men are three times more likely to be affected than women and the lifetime risk of developing a calculus in a Caucasian man is nearly 20%. Figure 1 outlines the possible causes of urolithiasis.

Clinical features
Pain is the most common presenting symptom of ureteric calculi and is caused by the stone obstructing the urinary tract. The three most common sites of obstruction are the pelviureteric junction, pelvic brim and vesicoureteric junction (although obstruction can occur at any point along the system). Classical renal colic is characterized by an acute onset of pain in the loin that radiates to the groin and scrotum (or labia majora). Often, the pain is severe and the patient will move around to obtain relief. Unlike conditions causing peritonism, the pain is not relieved by remaining motionless. Nausea and vomiting are also common with acute renal colic, in part due to a degree of ileus. Non-obstructing calculi may present with loin and/or groin pain, but pain which is less severe than that due to stones causing obstruction. Stones within the bladder will usually cause lower urinary tract symptoms such as dysuria, suprapubic discomfort, urgency and an unsuccessful desire to void (strangury). Haematuria is present in 8590 % of patients with stone and is usually microscopic (although frank blood may be observed). Haematuria may be absent (even on dipstick analysis) in up to 15% of patients. Infection may be a causal factor in stone formation or may be secondary to obstruction caused by the calculus. Typically, infection with urease-producing organisms causes alkalinization of the urine, leading to formation of magnesium ammonium phosphate stones which may become large staghorn calculi.

Any obstructing calculi can lead to secondary infection in the system proximal to the level of blockage. Severe infection can lead to frank pus in an obstructed system (pyonephrosis). The clinical presentation of the infected system can vary from asymptomatic bacteriuria to fulminant urosepsis. The condition will lead to renal damage and possibly death if untreated.

Investigations
Physical examination is often unremarkable apart from mild tenderness on the affected side. Pyonephrosis is indicated by marked tenderness in the renal angle and loin. Occasionally, no localizing symptoms or signs (even in the presence of fulminant pyonephrosis) are present. Urolithiasis should be considered as a differential diagnosis (Figure 2) for a pyrexia of unknown origin. Urea and electrolytes must be measured as an indicator of renal function. Possible metabolic causes for stone formation should be excluded by measurement of serum calcium, phosphate and uric acid. Levels of parathyroid hormone must be determined if the serum calcium is raised. A full blood count will reveal leukocytosis in patients with sepsis, although most patients with acute renal colic will show a mild leukocytosis as part of the acute-phase response. Dipstick urinalysis usually demonstrates haematuria. The pH may indicate the cause of the stone formation: alkaline (pH >7.5) urine suggests infection acidic (pH <5.5) urine suggests uric acid stones.
129

Ben Thomas is a Specialist Regsistrar in Urology on the North Trent Surgical Training Rotation, UK. James Hall is a Consultant Urological Surgeon at the Royal Hallamshire Hospital, Sheffield, UK.

SURGERY 23:4

2005 The Medicine Publishing Company Ltd

RENAL AND UROLOGY

Differential diagnosis of urolithiasis

Non-urological Appendicitis Diverticulitis Ectopic pregnancy Salpingitis Torsion of an ovarian cyst Ruptured abdominal aortic aneurysm Biliary colic Urological Tumour Pyleonephritis Retroperitoneal fibrosis Stricture Obstruction of the pelviureteric junction Papillary necrosis Renal infarction Testicular torsion

A mid-stream urine sample must be sent if infection is suspected because it may be a helpful guide in the event of sepsis. A stone analysis may help in the diagnosis of some of the more unusual types of stone formation. The most common composition of urinary calculi is calcium oxalate (60%), calcium phosphate (20%), uric acid (10%), magnesium ammonium phosphate (7%) and cystine (3%).

Imaging
Radiographs: as an initial test, a plain radiograph of the kidneys, ureters and bladder will show about 60% of calculi (Figure 3). Further plain radiographs are useful for following the progress of the stone (or response to treatment) if a stone is visible on the kidneysureterbladder radiograph. Non-contrast CT of the kidneys, ureters and bladder has recently become available and has superseded the intravenous urogram as the first-line investigation of urolithiasis in many units in the UK (Figure 4). Using modern multislice scanners, the investigation is rapid and carries none of the risks associated with contrast media. Diagnostic accuracy is >95% and extra-renal pathologies (e.g. abdominal aortic aneurysms, appendicitis, adnexal masses) can be diagnosed. However, non-contrast CT of the kidneys, ureter and bladder involves 1.52 times more radiation than a standard intravenous urogram. A plain radiograph of the kidneys, ureter and bladder must be obtained in combination with the non-contrast CT scan. If the stone is visible, further plain radiographs of the kidneys, ureter and bladder can be used for follow-up; if the stone is not visible, repeat non-contrast CT scans may be needed.
SURGERY 23:4

b Plain radiography. a A large staghorn calculus occupies the entire pelvicalyceal system b Multiple calculi in the bladder. 3

An intravenous urogram consists of a preliminary control kidneysureterbladder radiograph followed by an intravenous injection of iodinated contrast medium. Further kidneysureterbladder radiographs are then taken at predetermined time intervals until the relevant diagnostic information is obtained. Diagnostic accuracy of an intravenous urogram approaches 90% and it gives good anatomical information of the pelvicalyceal system and ureters. Some functional information can also be obtained because excretion of the contrast requires a functional renal unit. Obstruction is shown by a dense nephrogram and a lack of contrast entering the collecting system. The intravenous urogram has limitations. Visualization of the collecting systems can be obscured by faecal loading, overlying
130
2005 The Medicine Publishing Company Ltd

RENAL AND UROLOGY

Non-contrast CT. a Right hydronephrosis (arrow). b A stone in the distal right ureter (arrow). 4

bowel gas and bony structures. The quality of the images will also be reduced in patients with poor renal function. Another major limitation is the risk of contrast allergy or contrast interactions. The most common problem is patients taking metformin who are at risk of developing lactic acidosis. The contrast media is nephrotoxic in dehydrated patients with renal failure. Ultrasound can be used with a plain radiograph of the kidneys, ureter and bladder, and increases the diagnostic accuracy to 75%. It is inexpensive and non-invasive, but detection of stones (particularly those in the ureter) is limited. It is the first-line investigation in pregnancy or suspected pyonephrosis. Isotope renography involves intravenous administration of a radiopharmaceutical agent (labelled with technetium-99) and imaging with a gamma camera that allows assessment of uptake, transit and elimination by the kidney. Information about the relative function of the kidneys, the degree of obstruction and monitoring of changes in function of an obstructed kidney can be obtained, but depends on the radiopharmaceutical used. Function and obstruction can be assessed with dynamic renography using diethylenetriamine pentaacetic acid and mercaptoacetyltriglycine, whereas relative renal function is assessed using static renography with dimercaptosuccinic acid.

Conservative An initial predictor of outcome is stone size. Stones measuring 4 mm or less will pass spontaneously in about 80% of patients. However, this falls to only 10% for stones measuring 6 mm or larger. Thus, adopt a conservative approach with stones <4 mm. The patient can be reviewed in the Outpatient Clinic 24 weeks after discharge from hospital; a recent plain radiograph is taken to assess movement of the stone. This approach relies on whether the stone was visible on a plain radiograph at presentation, and this must be documented. Other scenarios where a conservative approach should be employed are smaller renal calculi, medullary sponge kidney, and stones in calyceal cysts. Comorbidity may also favour conservative management (especially with renal stones). Indications for intervention Relative indications for intervention include: intractable pain large stone failure of progression occupation (e.g. airline pilots). The absolute indications for intervention are urosepsis and deteriorating renal function. In pyonephrosis, placement of a percutaneous nephrostomy drain is the first-line treatment and, in the authors experience, is safer and more reliable than any form of retrograde intervention (stent placement or ureteroscopy). This approach also facilitates future antegrade studies, allows antegrade stent placement and can provide access for percutaneous stone surgery. Occasionally, decompression will allow spontaneous passage of the stone.
131

Management
Patients presenting with acute renal colic should be given analgesia (e.g. diclofenac (preferably per rectum)) or pethidine and antiemetics as required. Usually, one or two doses will be sufficient An alternative diagnosis must be considered if repeat doses of analgesics are required.

SURGERY 23:4

2005 The Medicine Publishing Company Ltd

RENAL AND UROLOGY

Treatment Extracorporeal shockwave lithotripsy is a widely available (in the UK) and well-tolerated modality for the treatment of renal pelvis and ureteric calculi. It is non-invasive, does not require anaesthesia and has comparable results to ureteroscopy (especially for more proximal stones). However, multiple treatments may be required and the patient may continue to experience symptoms during this time. The elements of a lithotripter are an energy source (to create the shock wave), a coupling mechanism (usually a water-filled membrane) to transfer the energy from outside to the inside of the body, and fluoroscopic or ultrasonic imaging (or both) to locate the stone and position it at a focus of converging shockwaves. Energy source there are three main types. Electrohydraulic an underwater spark discharge generates a hydrodynamic pressure wave, which is released at the focal point of a parabolic reflector. Electromagnetic a charge difference between two plates causes motion and generation of a shockwave which can be focused by an acoustic lens. Piezoelectric an array of piezocrystals arranged in a semicircular fashion, focused at the centre of its sphere, generate peak pressures sufficient for stone fragmentation. Contraindications for lithotripsy are: uncorrected coagulopathy urosepsis pregnancy renal artery aneurysm or large aortic aneurysm. Immediate complications are infection, renal haemorrhage/ haematoma, injury to adjacent organ, arrhythmia, and a column of obstructing fragments in the ureter (steinstrasse) Delayed complications are possible hypertension and renal damage. Ureteroscopy is the examination of the ureter using a specially designed ureteroscope. The principles of construction are similar to the cystoscope, but the instrument is much narrower and longer. There are two main types: semi-rigid and flexible. Semi-rigid scopes are constructed of metal and, though it is often possible to advance a semi-rigid ureteroscope into the renal pelvis, this instrument is primarily used for accessing and fragmenting stones within the ureter. Flexible ureteroscopes have fully moveable tips, similar to other types of flexible endoscope. This manoeuvrability permits access to all parts of the renal collecting system (including the pelvis and the calyces). Stone clearance rates are comparable with other techniques when used in combination with laser lithotripsy. All types of ureteroscope have at least one working channel through which instruments (e.g. guidewires, fragmentation devices stone retrieval instruments) can be passed. Most stones encountered ureteroscopically require some form of fragmentation in order to facilitate removal. The two most commonly used methods of endoscopic lithotripsy are ballistic and laser lithotripsy. Both methods can be employed via a semi-rigid ureteroscope, but only laser lithotripsy can be used through a flexible ureteroscope (due to the flexibility of the fine laser fibres). Ballistic lithotripsy (e.g. Lithoclast) uses a direct-contact, solid, rigid probe to fragment the calculus.
132

Laser lithotripsy uses the holmium/YAG thermal laser. It vaporizes calculi and produces fine fragments. The penetration of this laser through water and tissue is extremely shallow, reducing the risks of ureteric damage. Percutaneous nephrolithotomy permits endoscopic access directly into the renal collecting system and upper ureter. Access to an appropriate calyx is obtained via a needle puncture under radiological guidance. A guidewire is inserted to the collecting system, over which the tract is dilated (to 30 Fr) with a pressurized balloon or a series of graduated dilators. Once dilated, the tract is maintained by an Amplatz sheath, through which a nephroscope is introduced. Fragmentation of the stone can be accomplished using the lithotripsy techniques described above. The large gauge of the sheath and the nephroscope enables large volumes of stone to be removed in a single sitting. Following the procedure, a nephrostomy tube drain is usually left in situ and a ureteric stent may also be placed. Complications of percutaneous nephrolithotomy are: infection haemorrhage pleural/lung damage (higher risk in upper-pole punctures) residual stone fragments renal parenchymal damage damage to other organs (e.g. colon). Laparoscopic surgery is an option for ureteric stones which are difficult to manage or clear using endoscopic methods. Stones in a kidney with obstruction of the pelviureteric junction can also be removed laparoscopically at the time of definitive pyeloplasty. Open surgery for stone disease is very uncommon in the UK. Nephrectomy is often the first-line treatment in a poorly functioning kidney containing stones. Such cases are often difficult to manage due to scarring around the kidney, but a laparoscopic approach should be considered initially. In patients with larger vesical calculi, a relatively quick open cystolithotomy may be safer than a prolonged endoscopic operation (especially if significant comorbidity exists). Dissolution therapy: the best results are obtained in patients with uric acid stones. A combination of high intake of fluid, urinary deacidification with high doses of potassium citrate, and administration of allopurinol can lead to dissolution of these stones. Which treatment for which stone? Deciding which intervention should be used for a particular stone will depend on: the location and size of the stone previous interventions abnormal or unfavourable anatomy of the urinary tract availability of different treatment modalities patient wishes. A staged approach (possibly using more than one technique) may be necessary. The aim is to render the patient stone-free using as few interventions as possible. Renal stones: percutaneous nephrolithotomy should be first-line treatment in larger (especially staghorn) calculi or if the calyceal

SURGERY 23:4

2005 The Medicine Publishing Company Ltd

RENAL AND UROLOGY

anatomy is abnormal (e.g. dilated collecting system). In some large stones, the bulk may be removed with percutaneous nephrolithotomy and any remaining small fragments can be treated with extracorporeal shockwave lithotripsy (sandwich therapy). Complex staghorn stones may require multiple punctures. Extracorporeal shockwave lithotripsy is the initial treatment for stones up to 2 cm in diameter with normal collecting system anatomy. Stones >2 cm in diameter have much lower stone clearance rates with extracorporeal shockwave lithotripsy, so percutaneous nephrolithotomy is preferred. Pre-placement of a ureteric stent may increase the safety of treating larger stones with extracorporeal shockwave lithotripsy because it can help avoid steinstrasse. Small symptomatic stones in a lower pole calyx may not clear with extracorporeal shockwave lithotripsy and flexible ureteroscopy with laser fragmentation may be more successful. This approach may also be useful for: stones in the upper pole that cannot be reached safely with percutaneous nephrolithotomy patients with renal and ureteric stones patients who are unfit for general anaesthesia. Ureteric stones which do not pass spontaneously can often be treated with extracorporeal shockwave lithotripsy. However, proximity to bony structures (especially in the pelvis) can create difficulties with respect to visualization and energy delivery. Ureteroscopy with stone fragmentation is more likely to clear a stone at a single visit compared to extracorporeal shockwave lithotripsy. Endoscopic treatment of lower ureteric stones can achieve stone-free rates in >90% of cases after one treatment. Ureteroscopy is the first-line treatment (Figure 5) if extracorporeal shockwave lithotripsy is contraindicated or has failed. Bladder stones are usually a manifestation of underlying pathology such as high residual urine (due to detrusor failure or obstruction). The principle of treatment is to deal with the underlying condition and the stone. Most stones can be dealt with endoscopically. Cystolitholopaxy involves crushing the stone with a mechanical lithotrite (large stone-crushing forceps), and the fragments are irrigated from the bladder. Larger stones can be fragmented using the forms of endoscopic lithotripsy described above. Open cystolithotomy may occasionally be required for larger stones or endoscopic failures.

Complications of urinary calculi

Obstruction at any site in the urinary tract. Infection is usually secondary to obstruction. Renal damage an obstructed infected kidney becomes rapidly damaged within days. In the absence of infection, damage may take months due to various coping mechanisms (e.g. pyelovenous backflow) dependent on the degree of obstruction. Tissue damage may result in fibrosis and ureteric strictures. Squamous cell carcinoma may occur in patients with staghorn calculi or large bladder calculi with associated chronic inflammation. Xanthogranulomatous pyelonephritis is rare, but is usually associated with obstruction due to a renal calculus. The condition represents the end-stage of chronic inflammation. Nephrectomy can be profoundly difficult due to infiltrative fibrosis. Xanthogranulomatous pyleonephritis can be mistaken for a renal tumour on imaging.

Prevention of recurrence
The risk of recurrent calculi is high; 50% of patients will experience a recurrence within 10 years after the initial stone episode. Risk factors should be modified where possible. Simple, general dietary advice is adequate for most patients. Metabolic analysis in selected patients can identify specific abnormalities which can be corrected by dietary or medical intervention. Maintaining a good intake of fluid reduces the risk of recurrence and patients should aim for a urine output of 2 l per day. Intake of dietary oxalate and sodium should be limited because it can reduce urinary excretion of oxalate and calcium; reducing the intake of calcium can increase the rate of stone recurrence. Potassium citrate and thiazide diuretics can inhibit calculus formation and, in combination with high intake of fluid, are the most effective recurrence prevention regimens for calcium stones. However, both agents have significant side-effects (e.g. pancreatitis with thiazides; nausea with citrates) and patient compliance is often poor. Uric acid stones can be prevented by reducing intake of animal protein. Deacidification of the urine using potassium citrate is useful. Allupurinol 300 mg o.d. should be given if levels of uric acid in serum are elevated.

FURTHER READING Munver R, Preminger G M. Urinary tract stones. In: Weiss R M, George N J R, OReilly P H (Editors). Comprehensive urology. London: Mosby, 2001. Tiselius H G. Epidemiology and medical management of stone disease. BJU Int 2003; 91: 75867.

5 Instruments used in the endoscopic management of calculi. 1 Flexible ureteroscope; 2 Semi-rigid ureteroscope; 3 Lithoclast; 4 Ureteric catheter; 5 Guidewire; 6 Ureteric stent.

The authors are indebted to Ken Hastie (Clinical Director and Consultant Urological Surgeon at the Royal Hallamshire Hospital, Sheffield, UK) for his significant contribution to this review article.

SURGERY 23:4

133

2005 The Medicine Publishing Company Ltd