‫بسم هللا الرحمن الرحيم‬

Introduction
• Urolithiasis is calculus formation occur at any level in the urinary
collecting system.
• It often originates in the kidney.
• Nephrolithiasis (renal stones)—stones within the collecting
system of the kidney.
• A primary bladder stone is one that develops in sterile urine.
• A secondary stone occurs in the presence of infection, outflow
obstruction, impaired bladder emptying or a foreign body.
 Introduction

• Age: Peak age is between 20 and 30 years.

• Sex: More common in men than in women.
• Site: Kidneys are the most common site for calculi formation.
• A familial tendency toward stone formation has been
recognized
 Introduction
• Stones are unilateral in about 80% of patients.
• They may be single or multiple.
• Stones may have smooth contours or may be irregular, jagged
mass of spicules.
 Etiology
1. Familial and hereditary factors:
• family history of renal stone increases the risk of developing renal
stone.
2. Hypercalciuria: (increased calcium in urine) in the absence of
hypercalcemia
• Most common metabolic abnormality producing stones.
• Caused by increased gastrointestinal reabsorption of calcium;
called absorptive hypercalciuria
 Etiology
3. Inborn errors of metabolism: (e.g gout, cystinuria, and primary
hyperoxaluria) are characterized by excessive production and
excretion of stone-forming substances.
4. Diet:
A. Deficiency of vitamin A causes desquamation of epithelium and
these cells may form a nidus on which a stone can be deposited.
B. Diets high in dairy products (contain phosphate) or oxalates form
calcium phosphate and calcium oxalate stones.
 Etiology
5. Infection:
• Infection favors the formation of calculi.
• Stone formation are common when urine is infected with urea-
splitting streptococci, staphylococci and, especially Proteus.
 Etiology
6. Altered urinary solutes and colloids:
• Dehydration increases the concentration of urinary solutes
and are liable to precipitate.
• Decreased urinary citrate: Citrate in urine present as citric
acid and is under hormonal control. It tends to keep relatively
insoluble calcium phosphate and citrate in solution.
 Etiology
7. Urine pH alterations:

(a) Alkaline urine pH favors crystallization, which

produces calcium- and phosphate-containing stones.

(b) Acidic urine pH favors crystallization of uric acid and

cysteine, which produces uric acid and cysteine stones.
 Etiology
• 8. hypercalcemia:
• Primary hyperparathyroidism (HPTH; 10% of cases) increases urine
calcium concentration, producing calcium-containing stones.
• Bone disease.
• Malignancy.
• etc
 Pathogenesis of Renal Stones
• There are two main factors involved in stone formation:
1. Super saturation: it is super saturation of urine by stone constituents.
• It is the most important factor in stone formation.
• This may be due to:
A. increased urinary concentration of stone constituents who exceeds their
solubility.
B. Decreased urine volume: which concentrates the urine this favors super-
saturation, therefore Hydration is essential in preventing stone
formation
 Pathogenesis of Renal Stones
2. Precipitation of crystals:
• Deficiency in inhibitors of crystal formation in urine enhances precipitation
of crystals.
• Inhibitors include: pyrophosphates, citrates, glycosaminoglycans,
osteopontin … etc..
• All calculi consist of an organic mucoprotein matrix, which makes up 1% to
5% of the stone by weight.
• The mucoproteins in the urine provide the organic nidus on which the
crystals form.
 Types of Renal Stones
• There are four main types of calculi:
1. Calcium stones (~80%): Composed of calcium oxalate or calcium
phosphate or mixture of both.
2. Triple stones or struvite stones (~10%): Composed of
magnesium, ammonium and phosphate.
3. Uric acid stones (~7%).
4. Cystine stones
Calcium Stones (Oxalate Calculus/Calcium Oxalate)
• Most (80%) renal stones are calcium stones.
• Composed of calcium complexed with oxalate (calcium
oxalate) or phosphate (calcium phosphate) or a mixture of
these (calcium oxalate + calcium phosphate).
• These stones are radiopaque.
Calcium stones
Struvite Stones or (Triple stones/Magnesium,
Ammonium, Phosphate Stones)

• They are composed of calcium phosphate often with

magnesium and ammonium phosphate,
• and are known as struvite stones or triple phosphate stones.
Etiology
• They develop after infections of the urinary tract by urea-
splitting bacteria (e.g. Proteus).
• It convert urea to ammonia produces alkaline pH + slowing
of urine flow precipitation of magnesium, ammonium,
phosphate (struvite), and calcium phosphate.
Morphology
staghorn
stones
Struvite renal stones
Radiology
 Uric Acid and Urate Stones
• Etiology
• Commonly found in patients with hyperuricemia (e.g. gout)
and diseases involving rapid cell turnover (e.g. treatment of
leukemia).
• However, more than 50% of patients have neither
hyperuricemia nor increased urinary excretion of uric acid.
• Uric acid is insoluble in acidic urine and urine pH below 5.5
may predispose to uric acid stones.
Uric acid stones
4. Cystine Stones
• Etiology:
• Cystine stones are uncommon and associated with cystinuria,
which is due to genetic defects in the renal reabsorption of
cystine or other amino acids.
• Stones form at low urinary pH (acidic urine).
Cysteine stones
Diagnosis
• Clinical features.
• Radiological investigations.
• Laboratory investigations.
• Cystoscopy.
Clinical Features of Renal Stones

• Clinical features depends on site of stone.

• Stones may be asymptomatic.
• Small stones may pass into the ureters, producing colic and
ureteral obstruction.
 Clinical features
• Large stones cannot enter the ureters and likely to remain
silent within the renal pelvis.
• Larger stones may cause ulceration and present with
hematuria.
• Stones also predispose to superimposed infection and
present with features of UTI.
• It may also cause significant renal damage leading to renal
failure.
Laboratory findings.
A. Urine analysis:
• Hematuria.
• Pus cells: urinary tract infection.
• Crystals in urine.
• B: Blood for:
1. Renal function test.
2. Serum calcium --> Hypercalcemia.
3. Serum for PTH: Increase PTH e.g. primary HPTH.
Complications of Renal Stones
• Hematuria.
• Hydronephrosis due to obstruction.
• Pyelonephritis and pyonephrosis.
• Carcinoma: Stones can cause squamous metaplasia and later
squamous cell carcinoma.
Hydronephrosis
Hydronephrosis
 Treatment of renal stones
• Analgesia for persistent pain.
• Antibiotics if the patient presents with urinary tract
infection.
• Surgery.
• Shock wave lithotripsy.
Thank you