TOPIC – 9 – UROLITHIASIS

1. RISK FACTORS OF STONE FORMATION.

• Family or personal history.

• Dehydration. Not drinking enough water each day can increase your risk of kidney stones. People
who live in warm, dry climates and those who sweat a lot may be at higher risk than others.
• Certain diets. Eating a diet that's high in protein, sodium (salt) and sugar may increase your risk of
some types of kidney stones. This is especially true with a high-sodium diet. Too much salt in your
diet increases the amount of calcium your kidneys must filter and significantly increases your risk of
kidney stones.
• Obesity. High body mass index (BMI), large waist size and weight gain have been linked to an
increased risk of kidney stones.
• Digestive diseases and surgery. Gastric bypass surgery, inflammatory bowel disease or chronic
diarrhea can cause changes in the digestive process that affect your absorption of calcium and
water, increasing the amounts of stone- forming substances in your urine.
• Other medical conditions such as renal tubular acidosis, cystinuria, hyperparathyroidism and
repeated urinary tract infections also can increase your risk of kidney stones.
• Certain supplements and medications, such as vitamin C, dietary supplements, laxatives (when
used excessively), calcium-based antacids, and certain medications used to treat migraines or
depression, can increase your risk of kidney stones.

2. CLINICAL PRESENTATION AND DIAGNOSIS OF RENAL STONE .

ANS: Symptoms
A kidney stone usually will not cause symptoms until it moves around within your kidney or passes
into your ureters — the tubes connecting the kidneys and the bladder. If it becomes lodged in the
ureters, it may block the flow of urine and cause the kidney to swell and the ureter to spasm, which
can be very painful. At that point, you may experience these signs and symptoms:
• Severe, sharp pain in the side and back, below the ribs
• Pain that radiates to the lower abdomen and groin
• Pain that comes in waves and fluctuates in intensity
• Pain or burning sensation while urinating
Other signs and symptoms may include:
• Pink, red or brown urine

• Cloudy or foul-smelling urine

• A persistent need to urinate, urinating more often than usual or urinating in
small amounts
• Nausea and vomiting
• Fever and chills if an infection is present
Pain caused by a kidney stone may change — for instance, shifting to a different location or
increasing in intensity — as the stone moves through your urinary tract.

3.COMPLICATIONS OF RENAL STONES.

Complications could include:
• sepsis, an infection that spreads through the blood, causing symptoms throughout the whole body
• a blocked ureter caused by stone fragments (the ureter is the tube that attaches the kidney to the
bladder)
• an injury to the ureter
• a urinary tract infection (UTI)
• bleeding during surgery
• pain
4. METHODS OF TREATMENT OF RENAL STONES
• Blood testing. Blood tests may reveal too much calcium or uric acid in your blood. Blood test
results help monitor the health of your kidneys and may lead your doctor to check for other medical
conditions.
• Urine testing. The 24-hour urine collection test may show that you're excreting too many stone-
forming minerals or too few stone-preventing substances. For this test, your doctor may request
that you perform two urine collections over two consecutive days.
• Imaging. Imaging tests may show kidney stones in your urinary tract. High- speed or dual energy
computerized tomography (CT) may reveal even tiny stones. Simple abdominal X-rays are used less
frequently because this kind of imaging test can miss small kidney stones.
• Ultrasound, a noninvasive test that is quick and easy to perform, is another imaging option to
diagnose kidney stones.
• Analysis of passed stones. You may be asked to urinate through a strainer to catch stones that you
pass. Lab analysis will reveal the makeup of your kidney

5. STAGHORN STONES: CLASSIFICATION , CLINICAL FEATURES , DIAGNOSIS, TREATMENT.

: Staghorn Stones
A staghorn kidney stone is a term used to describe a large stone that takes up more than one branch
of the collecting system in the renal pelvis of the kidney.
By way of review, the urinary tract begins with the kidneys.
The kidneys, one on each side, sit high in the upper abdomen partially underneath the rib cage. They
filter the blood to extract excess waste products and fluid to form the urine. Urine, once formed in
the kidneys, is collected in the renal pelvis, the first part of the urinary drainage system. Urine travels
through a tube on each side, the ureter, down to the bladder. Urine is constantly being made by the
kidneys and transported through the ureters into the bladder. The bladder stores urine until full and
then empties to the outside through the urethra. The urinary system is the same in both men and
women from the kidneys to the bladder. In men, the urethra is longer and encircled by the prostate
which is a gland that is part of the reproductive system.

Recommendations
A patient with a staghorn stone should be treated.
If a staghorn stone is not treated, then renal deterioration occurs in at least 1 out of 4 patients. Over
time, an untreated staghorn calculus is likely to destroy the kidney and/or cause life-threatening
infections (sepsis). Complete removal of the stone is important in order to eradicate infection,
relieve obstruction, prevent further stone growth, and preserve kidney function.
Types of Treatment
Types of treatment include: Percutaneous nephrolithotomy (PNL), combinations of PNL and shock-
wave lithotripsy (SWL) (see ESWL newsletter), SWL alone and open surgery.
In some cases the staghorn stone may have already caused significant damage to the affected kidney
and the kidney may not contribute much to the overall level of a patient’s kidney functioning. An
imaging study called a Lasix renal scan may help determine if the Kidney has any significant function.
If the kidney does not work, and there’s chronic infection or pain, then removal of the kidney may be
recommended (see nephrectomy newsletter).
Stone-free Rates and Complications
To help decide how to proceed, it is worthwhile to consider the stone-free rates and the potential
complications. A useful way to interpret this information is to consider the following: a staghorn
stone can pose a significant risk to a patient’s health;
Complications
Estimated rates for overall significant complications are similar for the four therapeutic modalities
and range from 13% to 19%.
For PNL: acute loss of kidney; colon injury; hydrothorax; perforation; pneumothorax; prolonged leak;
sepsis; ureteral stone; vascular injury.
For SWL: acute loss of kidney; colic requiring admission; hematoma (significant); obstruction;
pyelonephritis; sepsis; steinstrasse; ureteral obstruction.
For combination therapy: any listed for the above plus deep vein thrombosis; fistula; impacted
ureteral stones; renal impairment.

6. STONES OF THE URETER: CLINICAL PRESENTATION , DIAGNOSIS, TREATMENT.

Ureteral stones:
Ureteral stones are kidney stones that have become stuck in one or both ureters.
Kidney or ureteral stones are diagnosed by
• Give you a physical exam and ask about your medical history.
• Test your urine to see if it contains substances that form stones.
• Test your blood to see if you have health problems that may have led to stones.
• Order an imaging test to find the location of the stones. Imaging tests may also help to see if you
have health problems that may have led to stones. Ultrasound is an effective imaging test to look for
blockage. A computed tomography (CT) scan will help guide therapy by informing the doctor of the
size, location, and hardness of the stone.

How are ureteral stones treated?

Treatment of ureteral stones depends on the size and location of the stones and the substances
from which they are formed. Treatment may also be directed by your current circumstances, such as
obesity, the use of anticoagulants (blood thinners), and other considerations. The size and location
of the stone will give you an idea of the likelihood that you can pass it.
If you have larger stones and your urinary tract is blocked, a urologist (a doctor who specializes in
the urinary tract) may treat you with the following:
• Shock wave lithotripsy
• Ureteroscopy
• Percutaneous nephrolithotomy

7. CLINICAL PRESENTATION , DIAGNOSIS, AND TREATMENT OG BLADDER STONES.

Diagnosis
Diagnosing bladder stones may involve:
• A physical exam.
• A urine test.
• CT scan.
• Ultrasound.
• X-ray.
Treatment
Drinking lots of water may help a small stone pass naturally. However, because bladder stones are
often caused by difficulty emptying your bladder completely, extra water may not be enough to
make the stone pass.
Most of the time, you'll need to have the stones removed. There are a few ways to do this.
Breaking stones apart
In one method, you're first given numbing medication or general anesthesia to make you
unconscious. After that, a small tube with a camera at the end is inserted into your bladder to let
your doctor see the stone. Then, a laser, ultrasound or other device breaks the stone into small
pieces and flushes them from the bladder.

Surgical removal
Occasionally, bladder stones are large or too hard to break up. In these cases, your doctor will
surgically remove the stones from your bladder.
If your bladder stones are the result of a bladder outlet obstruction or an enlarged prostate, these
problems need to be treated at the same time as your bladder stones, typically with surgery.
Bladder stone:
Bladder stones are hard masses of minerals in your bladder. They develop when the minerals in
concentrated urine crystallize and form stones. This often happens when you have trouble
completely emptying your bladder.

Symptoms
Sometimes bladder stones — even large ones — cause no problems. But if a stone irritates the
bladder wall or blocks the flow of urine, signs and symptoms may include:
• Lower abdominal pain
• Pain during urination
• Frequent urination
• Difficulty urinating or interrupted urine flow
• Blood in the urine
• Cloudy or abnormally dark-colored urine

8. PERFORM DIFFERENTIAL DIAGNOSIS OF BLADDER STONE FROM CYSTITIS , BLADDER TUMOR.

The differential diagnosis of bladder stone include the following:

• Fungus ball
• Clot
• Papillary urothelial carcinoma on a stalk
• Calculus

Differential diagnoses of bladder cancer

Most symptoms from the urinary tract are caused by benign conditions. There are no specific cancer
symptoms.
Patients with macroscopic hematuria without other symptoms are tested for malignant tumors, but
this may also be due to:
• bleeding from vessels in the prostate from benign prostate hyperplasia (BPH)
• renal pelvic calculi
• bladder calculi
• kidney cancer with infiltration to renal pelvis
• microhematuria from chronic kidney/urinary tract infections Problems urinating are common
from:
• cystourethritis - many of these symptoms can occur from BPH
• hormone-related dysuria in women during/after menopause

Differential Diagnosis OF CYSTITIS;

In female patients who present with dysuria, differential diagnoses include vaginitis and urethritis.
Vaginitis is usually associated with vaginal discharge, dyspareunia, and pruritus and causes include
bacterial vaginosis, trichomoniasis, or yeast infection. Painful bladder syndrome may be considered
in patients with persistent symptoms of bladder discomfort but with no evidence of infectious
etiology. This is, however, a diagnosis of exclusion. In men with lower UTI symptoms, prostatitis
must be ruled out especially when associated with fever, malaise, perineal pain, and obstructive
urinary symptoms. Recurrent UTIs in male patients should heighten suspicion for chronic bacterial
prostatitis.
9. PROSTATIC CALCULI : ETIOLOGY , CLINICAL PRESENTATION , DIAGNOSIS, TREATMENT.

Prostatic calculi often occur in middle-aged and old men. Prostatic calculi are usually classified as
primary/endogenous stones or secondary/extrinsic stones. Endogenous stones are commonly
caused by obstruction of the prostatic ducts around the enlarged prostate by benign prostatic
hyperplasia (BPH) or by chronic inflammation. Extrinsic stones occur mainly around the urethra,
because they are caused by urine reflux. The exact prevalence of prostatic calculi is not known, and
it has been reported to vary widely, from 7% to 70%. Most cases of prostatic calculi are not
accompanied by symptoms. Therefore, most cases are found incidentally during the diagnosis of BPH
using transrectal ultrasonography (TRUS). However, prostatic calculi associated with chronic
prostatitis may be accompanied by chronic pelvic pain. Rare cases have been reported in which
extrinsic prostatic calculi caused by urine reflux have led to voiding difficulty due to their size. More
than 80% of prostatic calculi are composed of calcium phosphate.

DIAGNOSIS AND TREATMENT OF PROSTATIC CALCULI

Prostatic calculi are mainly found using TRUS in the process of diagnosing lower urinary tract
symptoms. Harada et al divided patients into 2 groups according to the echo patterns of prostatic
calculi: (1) type A: discrete, multiple small echoes, usually diffusely distributed throughout the gland
and (2) type B: a large mass of multiple, coarser echoes. In addition to TRUS, a computed
tomography (CT) scan or a kidney, ureter, and bladder x-ray may find prostatic calculi incidentally,
but in most cases, finding prostate calculi is not the goal; thus, even if they are diagnosed, they are
mostly clinically meaningless. are TRUS and CT images, respectively, of the same patient.
Pelvic computed tomography. Arrows indicate prostatic calculi.
Prostatic calculi are mostly asymptomatic, but in some cases, a large prostatic calculus protruding
into the urethra causes severe lower urinary tract symptoms such as urinary obstruction. In such
cases, the prostatic calculi can be removed with a transurethral endoscope. Prostatic calculi
associated with benign prostatic hyperplasia tend to occur in adjacent areas of the glomeruli, as the
compressed prostate ducts surrounding the glandular mass are occluded. Prostatic calculi observed
on the border of enlarged prostate tissue during TURP also act as a boundary for prostate capsules
during TURP, and can be easily removed by endoscopic resection. In a study of 183 patients with
benign prostatic hyperplasia who underwent TURP, Jeon et al reported that the group with prostatic
calculi showed a greater improvement in lower urinary tract symptoms after TURP than the group
without prostatic calculi. For calculi around the urethra (between the periurethral prostatic gland
and the urethra) and around the adenoma (between the adenoma and the prostate tissue), it was
shown that the greater the number of prostate calculi removed, the more significant was the change
in lower urinary tract symptoms. However, calculi were not associated with any difference in
patients with diffuse scattering in the central or peripheral region. Multiple calculi in the peripheral
zone can be difficult to remove entirely with these surgical treatments.
Prostatic calculi, which are usually symptomless, generally require no special treatment. However,
the most problematic cases of prostatic calculi are associated with chronic prostate inflammation. In
this case, treatment with antibiotics combined with the treatment of prostatitis may cause the
symptoms to disappear. However, because prostate calculi contaminated with bacteria are a source
of persistent inflammation, the thorough elimination of prostate calculi is the preferred treatment
method for chronic bacterial prostate inflammation. Lee and Kim [24] analyzed the efficacy of oral
antibiotics in 64 patients with chronic bacterial prostatitis and reported that the healing rate using
pharmacotherapy was 63.6% in patients without calculi and 35.7% in those with calculi; they
emphasized the usefulness of TURP for the treatment of chronic bacterial prostate inflammation
rather than relying on medical treatment.