1. Urinary Stones (Urolithiasis).

2. Nephroptosis and hydronephrosis.

3. Nephrogenic Arterial Hypertension

Question: what is urolithiasis?

It is the process of stone formation in any part of the urinary system

Question: what is the etiology of urolithiasis?

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 hepatopathy;

 hepatogenic gastritis;

 Colitis, etc.

 C) Endocrine diseases

 hyperparathyroidism;

 hyperthyroidism;

 hypopituitarism diseases;

D.) Infect focuses of the urogenital system.

E) Metabolism disorders.

 essential hypercalciuria;

 disorders of membranes for colloid substances diffusion;

 renal rickets, etc

F) Injuries that lead 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:

 Retinol and ascorbic acid deficiency in food.

 Excessive amount of the ergocalciferol (vitamin D) in organism.

Question: what is the pathogenesis of urolithiasis?

There are 3 theories of urolithiasis;

1. Nucleation Theory:
This theory states that stone formation is initiated by the presence of a
crystal (foreign body) in urine supersaturated with a crystallizing salt that
favors growth of a crystal lattice.
2. Stone Matrix Theory:
This theory states that an organic matrix of serum and urinary proteins
(albumins, globulins, mucoproteins) provides a framework for deposition of
crystals
3. Inhibitor of Crystallization Theory: This theory states that absence or low
concentration of inhibitors of crystallization (eg, magnesium,
pyrophosphate, citrate, phosphocitrate, bisphosphonate, mucoproteins,
and various peptides) permits crystallization.

Question: name the different urinary stones in terms of their chemical

composition

1. Oxalate (calcium) stones (more common type); urine is low acidic

 2. Urate stones/uric acid stones (yellow brick color with a smooth surface and
hard consistency); acidic urine

3. Phosphate stones (urine is alkaline)

4. Cysteine stones (acidic urine)

Possible limits of oscillation of urine pH at nephrolithiasis is 5.5 – 7.7

Question: what are the symptoms and clinical course of the renal and ureteral
stones?

1. Renal colicky pain

 Obstructing calculi in the upper urinary tract severe sharp 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).

2. Tachycardia and hypertension may be present

3. Fever is rarely present except when a urinary tract infection accompanies
obstruction.
4. Nausea and vomiting
5. Sweating (diaphoresis)
6. The patient's abdomen is generally flat and soft, with moderate deep
tenderness on palpation where the calculus is lodged.
7. Some patients also have extensive hyperesthesia of the abdominal wall,
either anteriorly or posteriorly.
8. The costo-vertebral area may be tender to percussion.

Question: what is the diagnosis of urolithiasis?

1. CBC:
2. Biochemical blood analysis: high calcium, urate, albumin, creatinine may be
detected
3. Urinalysis: Microscopic or gross hematuria, pyuria and bacteriuria may be
present, presence of crystals, pH of urine may be alkaline or acidic
depending on the type of stone
4. Plain abdominal X-ray: radio-opaque stones (oxalate, cysteine and
phosphate) are observed. Nonradio-opaque stones (urate) are not
observed on observed on plain film

5. Excretory urography: delay in visualization of the collecting system on the

affected side, dilation of part proximal to stone, filling defect, dilatations,
distorted contours of calices.
In the absence of complete ureteral obstruction or a nonfunctional kidney,
a dense nephrogram will appear, followed by visualization of the collecting
system.
Excretory pyelography must not be carried out in the following patients -
those:
 With an allergy to contrast media
 With Serum creatinine level > 200 µmol/L
 On medication with metformin
 With myelomatosis
6. Retrograde pneumopyelography (best method for non-radiopaque stones
(urate) or the patient is allergic to contrast medium): small masses (stones)
filling defect, dilatations, distorted contours of calices

7. Retrograde pneumocystoscopy
8. CT scan

9. Ultrasound of abdomen: presence of hydronephrosis on acoustic

shadowing may be diagnostic.
Question: what is the differential diagnosis of urolithiasis?

This depends upon the position of the pain and the presence or absence of
pyrexia and includes:

1. Biliary colic.

2. Pyelonephritis: very high temperature. Pain is unlikely to radiate to the

groin.

3. Acute pancreatitis.

4. Acute appendicitis.

5. Perforated peptic ulcer.

Question: what is the principle of treatment of urolithiasis?

a. Conservative therapy
Pain relief involves the administration by various routes of the following
agents:
 NSAIDs (Diclofenac sodium , Indomethacin )
 Narcotics (Tramadol, morphine)
 Warm bath
 Spasmolytic “cocktails” (with papaverine, spasmalgone, no-spa, promedol)
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.

b. Instrumental therapy:
i. Loop extraction using Catheters (Council and Johnson baskets,
expandable Robinson baskets,
 retractable Dormia and Pfister-Schwartz baskets, end-loop and side-loop
Davis catheters, balloon catheters including double-balloon catheters,
and multiple ureteral catheters)

j. Extracorporeal short wave lithotripsy (ESWL): ultrasonic waves are

passed through the body until they strike the stone. These waves
break the stones into smaller particles and pass out through the urine.
c. Operative therapy
i. Percutaneous nephrostomy :
Utilize a nephroscope or ureteroscope
Extract with visualization
Break larger stones using ultrasonography

open stone removal

■ Rarely necessary, only when urinary calculi are not amenable to ESWL
or PL
■ Make an incision below the 12th rib
■ Expose the kidney and the ureter
 ■ Open the renal pelvis and extract the stone (or ureter in the case of a
ureteral stone)
■ Wash the entire calyx system
■ Suture the pyelon or the ureter

j. Contact lithotripsy

Question: what are the possible complications of operative management of

urolithiasis?
1. urinary tract infection,
2. hematuria,
3. ureteral perforation,
4. breakage and entrapment of the stone basket,
5. Complete avulsion of the ureter.

Question: what is hydronephrosis?

It is the permanent progression of dilation of the pelvico-caliceal system, followed
by the atrophy of the renal parenchyma and its dysfunction, caused by the urine
passage disorder.

Question: what is the classification of hydronephrosis?

1. Primary (congenital) and secondary hydronephrosis
2. Unilateral or bilateral
3. Aseptic or septic (infected)
4. Open, closed and intermittent
Question: what are the stages of hydronephrosis?
1. Stage I: pyeloectasy (dilation of just the renal pelvis with a moderate
dysfunction).
2. Stage II: prehydronephrosis (hydrocalicosis – the dilation of the renal pelvis
and calices, thinning of the parenchyma with expressed dysfunction.
3. Stage III: hydronephrotic atrophy, atony of the renal pelvis. This stage
means degeneration of kidney into great hollowed sack with fluid
Question: name the signs and symptoms of hydronephrosis
1. Usually asymptomatic
2. Nausea and vomiting
3. fatigue
4. In case of accompanying urinary tract infection, dull pain, fever may be
present
5. In case of accompanying urolithiasis, renal colic, hematuria occurs

Excretory urography retrograde urography

Question: what is the treatment principle of hydronephrosis?
The aim of treatment is to:
 remove the build-up of urine and relieve the pressure on the kidney(s)
 prevent permanent kidney damage
 treat the underlying cause of hydronephrosis (benign prostatic hyperplasia,
cancer of the prostate, neurogenic bladder, ureteral stone, posterior
ureteral valves, and ureteral stenosis)

Conservative method (for stage I of hydronephrosis):

1. urine drainage by catheterization
2. antibiotics

Operative method (II & III stage hydronephrosis):

1. Nephrostomy and drainage
2. Plastic by Anderson-Khinse
3. Plastic by Albaran
4. Nephrectomy (when there is an acutely expressed atrophy of
parenchyma and function is absent)

Question: what is nephroptosis (kidney prolapsus)?

It is the pathological state, at which a kidney is displaced far outside its physiology
mobility. Mostly it goes down vertically.

Question: what is the etiology of nephroptosis?

1. Unknown
2. Deficiency of supporting peri-renal fasciae and fat.
3. Risk factors include extreme loss of weight, severe hydronephrosis etc.
Question: name the 4 stages of nephroptosis
1. I stage: the lower kidney tip can be palpated,
No clinical symptoms.
2. II stage - all kidneys is palpated.
 Lumbar pain, hematuria, erythrocyturia, and proteinuria often accompany
a paroxysm of pain.
3. III stage - the kidney goes down pelvic region and freely moves in all sides.
Pain becomes permanent, moderate hypertension
4. IV stage - comes (rotary press) back around the longitudinal or transversal
axis.
Loss of kidney function, hematuria, leukocyturia, pyuria, fever, fatigue

1= pelvic (stage IV) 2= iliac (III) 3=lumbar (II) 4=intrathoracic 5=normal

position

Question: what is the diagnosis of nephroptosis?

1. History
2. Physical findings (palpation of kidneys in upright and horizontal positions)
3. CBC
4. Urinalysis
 5. Excretory urography

6. Renal arteriography

Question: what is the principle of treatment of nephroptosis?

1. Conservative (stage I)
-spasmolytic and anti-inflammatory medications,
 -Implementation complex of physical exercises for strengthening muscles of
anterior abdominal wall
2. Surgical (nephropexy of different methods)
Indications for surgical treatment are;
a. Frequent attacks of pyelonephritis,
b. nephrogenous hypertensіon,
c. hematuria,
d. expressed pains

Question: what is renovascular hypertension (nephrogenic hypertension)?

It is high blood pressure due to narrowing of the arteries kidneys (renal artery
stenosis).

Question: what is the pathogenesis of renovascular HPT?

1. Narrowing of the renal arteries decreases blood supply to the kidneys

2. The kidneys sense this as low blood pressure and thus release renin
3. Renin converts angiotensinogen into angiotensin I
4. In the lungs, angiotensin I is converted into angiotensin II by an enzyme
called angiotensin converting enzyme (ACE)
5. Angiotensin II is a vasoconstrictor and so causes vasoconstriction which
increases blood pressure
6. Also, angiotensin II stimulates the adrenal cortex to release aldosterone
which promotes sodium and water reabsorption from the kidney tubule
and thus raises the blood pressure

Question: what are the causes of renovascular HPT?

1. Atherosclerosis of renal vessels

2. Tumors compressing the renal vessels
3. Fibromuscular dysplasia
 4. Risk factors for atherosclerosis include high blood pressure, smoking,
diabetes, high cholesterol, heavy alcohol use, cocaine abuse, and increasing
age.
Question: name the signs and symptoms of renovascular HPT?
 High blood pressure at a young age
 High blood pressure that suddenly gets worse or is difficult to control
 Kidneys that are not working well, which often occurs suddenly
 Narrowing of other arteries in the body, such as to the legs, the
brain, the eyes and elsewhere
 Sudden buildup of fluid in the air sacs of the lungs (pulmonary
edema)
Question: what is the diagnostic principle of renovascular hypertension?
1. complete blood count,
2. biochemical blood test:
i. serum electrolytes (high sodium but low potassium)
ii. renin and aldosterone levels are high
3. Captopril challenge test: Peripheral plasma renin activity is measured
before and 1 h after administration of captopril (a converting-enzyme
inhibitor), 25 mg orally.
4. urinalysis and urine culture,
5. renal arteriography
6. renal ultrasound
7. Magnetic resonance angiography (MRA)
8. Helical (spiral) computed tomography
9. Electrocardiogram

Question: what is the principle of treatment of renovascular hypertension?

1. Medical
i. ACEI (lisinopril, captopril etc.)
ii. Angiotensin receptor blockers (ARBs); losartan
2. Surgical (angioplasty with or without stents)