UROLITHIASIS

 90% are radio-opaque

 Most common metabolic abnormality: Hypercalciuria

Etiology:
1. Anatomic – urinary obstruction and stasis
2. Urine composition
3. Low urine volume
4. Diet
- Cheese and egg yolk (high Potential Renal Acid Load PRAL)
- High sodium, Low fiber, High oxalate, carbonated drinks
5. Hypokalemia – intracellular acidosis
6. Comorbids
- Obesity, DM, HTN, Gout, Metabolic Acidosis, Cystinuria,
Sarcoidosis, IBD, Chronic diarrhea, Primary Hyperparathyroidism,
UTI, Sedentary lifestyle, Medications

UTI Increases Stone Risk

 UTI causes hypocitraturia (low urine citrate increases stone risk)
 Urease producing organisms split urinary urea into ammonia and
bicarbonate which alkalizes urine increasing risk for stone formation
(struvite)
 May decrease ureteral peristalsis

Acidosis and Stone Risk

 Acidosis causes increased urine calcium, increased urine phosphate,
decreased urine citrate

Medications that may induce stone formation

1. Vitamin C – metabolized to oxalate
2. Vitamin D – increases calcium absorption
3. Triamterene – precipitates in the urine and forms radiolucent stones
4. Protease Inhibitors – Indinavir and Nelfinavir (radiolucent)
5. Furosemide – increases calcium excretion in the urine

Acute Stone Episode

Work-Up
1. Hx and PE
2. WBC, UA, BUN, Crea, Urine CS
3. Imaging
Non-contrast
KUB
CT Stonogram (Adult)
Ultrasound (Pedia)
Contrast
Intravenous Urogram
CT Urogram
Nuclear Renal Scan

Indications for Prompt Intervention

1. Prolonged or complete high graded unilateral urinary obstruction
2. Bilateral urinary obstruction
3. Any obstruction in a solitary kidney
4. Obstruction with UTI or sepsis
5. Obstruction with rising creatinine
6. Severe nausea and vomiting
7. Severe pain

Treatment of Urolithiasis
General
Decompress – Treat UTI – Treat Stones

Bladder Stones
 Cystoscopic fragmentation and removal
 Percutaneous endoscopic fragmentation and removal
 ESWL
 Open stone removal
 Dissolution

Rena Stones (EAU Guidelines 2013)

Renal Stones <10mm
 If asymptomatic and stone is non-obstructing, OBSERVATION is an
option
  Ureteroscopy or ESWL

Renal Stones 10-20mm

 Lower pole stones and a higher risk of ESWL failure, URETEROSCOPY

Renal Stones >20mm

 PCNL

Uric Acid Stones

 Dissolution alone or combined with ESWL or PCNL

Staghorn Stones (AUA 2005 and EAU 2013)

 Most are struvite stones, can cause progressive renal damage and
persistent infection
 When observed, mortality I 11-30%
 Goal of treatment: complete stone removal
 PCNL since most staghorn are >20mm

Ureteral Stones (AUA/EAU 2007)

Stone Size <10mm
 Observation (Trial of Passage) specially <5mm, Ureteroscopy, ESWL
 Proximal ureter stones <10mm, ESWL has slightly higher stone free
rate vs ureteroscopy

Stone Size >10mm

 ESWL or ureteroscopy (preferred for distal stones >10mm)
 PCNL
o Large and impacted proximal stone
o Proximal ureteral stone with ipsilateral renal stone
o Patients with urinary diversion or renal transplant
o Failure of retrograde access to the ureter

Trial of Passage
 Adequate renal function
 Sufficient pain control
 Adequate oral intake
 Absence of infection
  Stone size <10mm
 More likely to pass if distally located and small in size
 68% pass <5mm
 Oral hydration, pain meds, a-blockers, CCB, steroids

Dissolution
 Calcium oxalate stones cannot be dissolved
 Uric acid stones
o Urine pH >6.5
o NaHCO3 or Potassium Citrate
 Cystine Stones
o Urine pH >7.5
o Potassium Citrate
 Struvite, brushite, apatite stones
o Irrigate with an acidic agent
 Suby’s G solution
 Hemiacidirin (Renacidin)
 Can be accomplished either
o Irrigate into the nephrostomy tube, into the ureteral stent,
out into the IC
o 2 nephrostom tube, in and out on the other
 Urine culture has no growth
 A pyelogram shows no extravasation, no leak around the tube, no
obstruction to flow

ESWL
 Only sedation is required
 Stone fragments are not removed (must pass)

Absolute contraindications:
 Pregnancy
 Coagulopathy
 UTI
 Intrarenal vascular calcification
 Renal artery or AAA

Relative contraindications
  Stone resistant to ESWL (cystine, matrix)
 Chronic pancreatitis with calcification
 Obstruction distal to the stone
 Obesity or malformation that hinder targeting the stone

 Stone are usually visualized using fluoroscopy

 Radiolucent – ultrasound or pyelogram
 Stone burden < 2-5mm highest when 60-90 shochs/minute
 Routine stenting is not recommended for ESWL
o Consider if stone burden > 1.5cm (prevents obstruction from
steinstrasse) or if bilateral ESWL
o Placed before ESWL on a solitary kidney

ESWL Failure
 Stone burden
 Stone composition
 Stone location – lower in lower pole (60% vs 70-90%)
 Impacted stone
 Obesity (skin to stone distance >10cm)

 ESWL causes decrease in renal blood flow and renal function for up to
3 weeks (decreased uptake and increased transit time)

Complications of ESWL
1. Intraoperative arrhythmia
- PVC
- More common in ESWL in the right side and during ESWL of renal
stones
- ECG gating ESWL to prevent arrhythmias
2. Renal / retroperitoneal hematoma
- When patients complain of an unusual amount of pain
- Obtain an abdominal or pelvic CT
3. Ecchymosis
4. UTI
5. Sepsis – in the presence of struvite stones
6. Pain – due to retroperitoneal hematoma
 7. Steinstrasse (stone street) – multiple fragments line up in the ureter
that may cause obstruction

PCNL
 Stone free rate 80-90% for renal and 86% for proximal ureteral
 Success rate independent of stone burden

Indications:
 Failure of other less invasive
 Renal stone burden >2.0cm
 Proximal ureteral stone >1.0cm
 Stone in calyceal diverticulum
 Uteropelvic junction obstruction with renal stones

Contraindications:
 UTI
 Coagulopathy
 Safe renal access is not possible

Complications:
 Bleeding
 Sepsis
 Renal pelvis perforation
 Pneumothorax / Hydrothorax
 Intraperitoneal Injury (Rare)
o Splenic
o Liver
o Bowel

Ureteroscopy
 Usually combined with endoscopic lithotripsy
 Goal is complete stone removal
 If ureteroscope cannot be safely passed, ureteral stent then come
back at least after 7 days
 Placing a stent after an uncomplicated procedure is optional (AUA
2007)
  A-blockers reduces pain during fragment passage and increases stone
free rate. When stone fragments exist, EAU 2013 recommends use of
a-blocker

Failure
 Stone burden
 Stone location – lower stone free rate in proximal stones

Complications
 Ureteral avulsion (<0.5%) – trying to extract a stone too large
 Ureteral perforation (<2%) – proximal (thinnest); treatment is placing
a stent for 6 weeks
 Submucosal tunneling – distal ureter
 Ureteral stricture (<1%) – AUA recommends upper tract imaging 3-6
weeks after ureteroscopy (ultrasound)
 UTI (4%)
 Vesicouretral reflux (<1%)