Urinary Tract

Stone
dr. Fakhri Rahman
Outlined

Sign and
Epidemiology Pathogenesis
Symptom

Diagnostic Management Follow Up

Epidemiology and Etiology
• Increases of Incidence and prevalence of
kidney stones
• Adult men > adult women (2-3:1) →
however incidence is narrowing
• Uncommon before age 20; peaks at 4th-6th
decade of life
• Highest incidence in the summer months
→ might be related to fluid losses
• Risk of stone disease correlated with
weight and BMI
• Systemic disease correlated with stone Prevalence Incidence
disease: DM, metabolic syndrome,
cardiovascular disease • Campbell Urology 11th ed.
• Romero et al. Kidney stones: a global picture of prevalence,
incidence and associated risk factor. Reviews in urology
 Pathogenesis

• Urine must be supersaturated for

stones to form.
• Supersaturation alone is not sufficient
for crystallization to occur in urine,
owing to the presence of urinary
inhibitors.

• Campbell Urology 11th ed.

 Classification of Stones
based on Etiology

• Non-infection
stones
• Infection stones
• Genetic causes
• Drug stones

EAU guidelines: urolithiasis

 Stone Composition and Relative Occurence

• The most common component

of urinary calculi is calcium,
which is a major constituent
of nearly 80% of stones.

• Campbell Urology 11th ed.

 Sign and Symptom

• Stone Location
• Upper, middle, lower calyx
• Renal pelvis
• Proximal or distal ureter
• Urinary bladder

EAU guidelines: urolithiasis

 Sign and Symptom

Pain Hematuria Infection

Associated Nausea and

Fever Vomiting

Smith and Tanagho’s General Urology

 Pain

• Renal colic vs non-colicky renal pain

• Colic pain → stretching of the collecting system
or ureter
• Non-colicky pain → distention of renal capsule
• Both may overlap and difficult to differentiate
• Stone in renal pelvis > 1 cm commonly
obstruct the ureteropelvic junction →
severe pain in CVA
• Radiating pain → Picture

Smith and Tanagho’s General Urology

Pain
Infection

• Pyonephrosis
• Gross purulent urine in an obstructed
collecting system
• If the condition is noted at the time of
PCNL → procedure should be aborted to
allow adequate drainage and start
antibiotic treatment
• If untreated → renocutaneous fistula
• Xanthogranulomatous pyelonephritis
• Associates with stone and obstruction
• Pathologic diagnosis with characteristic
foamy macrophag
• Urinalysis showes numerous red and white
cells
Smith and Tanagho’s General Urology
 Laboratory Analysis

EAU guidelines: urolithiasis

 Diagnostic Imaging

Ultrasound KUB / IVU

Non-Contrast CT-Scan Contrast Imaging

EAU guidelines: urolithiasis

Ultrasound

• Primary diagnostic imaging tool

• Identify stone in:
• Calyces
• Pelvis
• UPJ (ureteric-pelvic junction)
• UVJ (ureteric-vesica junction)
• Sensitivity 45%
• Specificity 94%
 Hydronephrosis and Pyonephrosis

radiopaedia.org
KUB

• Usually for follow up

• Should not be performed if NCCT is being considered
• IVU → provide information renal function and anatomy of urinary
tract
 Diagnostic Imaging

Stone X-Ray characteristics

EAU guidelines: urolithiasis

CT-Scan

• Non-contrast CT → standard for acute flank pain

https://teachmephysiology.com/urinary-
system/nephron/glomerulus/
 Stone analysis and Repeated stone analysis

• Stone analysis should be performed in all first-time

stone formers.
• In clinical practice, repeat stone analysis is needed in
the case of:
• recurrence under pharmacological prevention;
• early recurrence after interventional therapy with complete
stone clearance;
• late recurrence after a prolonged stone-free period

EAU guidelines: urolithiasis

Management

Conservative Medical Surgical

 Conservative (Observation)

• Prospective trial: support annual observation for

asymptomatic inferior calyceal stone < 10 mm.

• Intervention is advised for stone growing > 5 mm

EAU guidelines: urolithiasis

Medical Expulsive Therapy

• EAU guidelines: urolithiasis

 Active Stone Removal

• Active stone removal

• stone growth;
• stones in high-risk patients for stone formation;
• obstruction caused by stones;
• infection;
• symptomatic stones (e.g., pain or haematuria);
• stones > 15 mm;
• stones < 15 mm if observation is not the option of choice.
• patient preference;
• comorbidity;
• social situation of the patient (e.g., profession or travelling);
• choice of treatment.

EAU guidelines: urolithiasis

 Kidney Stones

EAU guidelines: urolithiasis

 Ureteral Stones

EAU guidelines: urolithiasis

 Extracorporeal Shock Wave Lithotripsy (SWL)

Tailly GG. Extracorporeal shock wave lithotripsy today. Indian Journal of Urology
 Extracorporeal Shock Wave Lithotripsy (SWL)

• Success depends on:

• Size, location and composition of stones
• Patient’s habitus
• Contraindications
• Pregnancy
• Bleeding diatheses
• Uncontrolled UTI’s
• Severe skeletal malformation and sever obesity (prevent targeting of the stone)
• Arterial aneurysm in the vicinity of the stone
• Anatomical obstruction distal to the stone

EAU guidelines: urolithiasis

 Extracorporeal Shock
Wave Lithotripsy (SWL)

• Lower pole anatomic

features which might
reduce stone passage in
SWL
• Narrow lower pole
infundibulum (width < 5
mm)
• Long infundibulum > 10
mm
• Acute lower
infundibulopelvic angle (<
90 degrees)
• HU > 1000
EAU guidelines: urolithiasis
 Extracorporeal Shock Wave Lithotripsy (SWL)

• Complications

EAU guidelines: urolithiasis

 Percutaneous Nephrolithotomy (PNL)

• Standard procedure for large renal calculi

• Current PNL technique available:
• Conventional PNL: > 22 Fr
• Mini PNL: 14-20 Fr
• Ultramini PNL : 11-13 Fr
• Micro PNL: > 4-8 Fr
• Contraindication
• Untreated UTI
• tumour in the presumptive access tract area;
• potential malignant kidney tumour;
• pregnancy
EAU guidelines: urolithiasis
USG-guided puncture and Fluoroscopy
Meatal Dilator & Amplatz Sheat
Lithotripsy and Stone Evacuation
 Percutaneous Nephrolithotomy (PNL)

• Complication

EAU guidelines: urolithiasis

URS / RIRS
 URS / RIRS

• URS can be performed in all patients without any specific

contraindications.
• The overall complication rate after URS is 9-25. Most are minor
and do not require intervention. Ureteral avulsion and
strictures are rare (< 1%)

EAU guidelines: urolithiasis

 Open Surgery / Laparoscopic

• Offer laparoscopic or open surgical stone removal in

rare cases in which shock wave lithotripsy, (flexible)
ureterorenoscopy and percutaneous nephrolithotomy
fail, or are unlikely to be successful.
• For ureterolithotomy, perform laparoscopy for large
impacted stones when endoscopic lithotripsy or shock
wave lithotripsy has failed.

EAU guidelines: urolithiasis

 Pyelolithotomy

Hinman’s Atlas of Urologic Surgery

 Pyelolithotomy

Hinman’s Atlas of Urologic Surgery

 Recurrence Prevention

EAU guidelines: urolithiasis

Pharmacological Substances
for Stone Prevention

EAU guidelines: urolithiasis

Thank You