Urolithiasis

Deepak K Thakur
MS, MCh (Urology)
• Introduction
• Risk Factors
• Types
• Presentation
• Diagnostic workup
• Treatment
• Prevention
 Introduction
• 3rd most common disorder of urinary tract
• Significant morbidity
• About 50% chance of recurrence within 5 year of
treatment
• Stone has basically two components
 Crystal component : ~90%
 Matrix component: ~2-10% of stone weight,
Composed of protein, hexose & hexosamine
• Stages of formation : Supersaturation>Nucleation >
Crystallization >Aggregation > Matrix formation >
Stone
 Etiology

• Diet :
 Vitamin A deficiency
 High animal protein & sugar
 Low dietary fiber
 High sodium intake
 Low water intake
• Infection : urea splitting organisms
• Socioeconomic factors : common in industrialized
country
• Occupation : sedentary life style
• Climate :hot climate
 Etiology

• Family History: 30% of stone formers have their first

degree relative with stone disease
• Metabolic Disorders:
 Hyperparathyroidism
 Hyperurecemia
 Hyperoxaluria
 Cystinuria
 Renal tubular acidosis
 Hypervitaminosis D
 Hypocitrateuria
 Hypomagnesemia
 Etiology

• Urinary stasis
• Drugs :
• Antihypertensive ( Triamterene )
• Antacids
• Carbonic anhydrase inhibitors
• Protease inhibitors
• Cytotoxic therapy
• Others : Sarcoidosis, medullary sponge kidney
 Types

• Calcium stones
• Noncalcium stones:
 Struvite
 Uric acid
 Cystine
 Xanthine
 Others :
o Indinavir stones
o Silicate stones
o Triamterene stones
 Types

• Calcium stones : calcium oxalate/Mulberry stones

o 80-85% of stones
o Radioopaque
o Brown with sharp projections
• Phosphate stones : struvite/triple phosphate
o 10-15% of stones
o Infected urine
o Smooth white
o radiopaque
 Types

• Uric acid stones :

o < 5% of stones
o Smooth ,hard, yellowish
o Radiolucent
• Cystine stones :
o Cystinuria : Inborn error of metabolism, autosomal recessive
condition
o Soft, yellow changes to greenish on exposure
o radiopaque
 Types

• Xanthine stones :
o Xanthine oxidase deficiency
o Smooth , brick red in colour
o Radiolucent
• Others :
• Indinavir : protease inhibitter, tannish red,
radiolucent
• Silicate stone : extremely rare, antacid associated
• Triamterene stone : triamterene containing
medications, radiolucent
 Presentation

• Asymptomatic
• Pain
• Nausea & vomiting
• Hematuria
• UTI
• Lithuria
• Renal failure
 Diagnostic workup

• Hematology
• Biochemistry :
RFT, Sugar, calcium, uric acid, special investigations
• Urine RE/ME: pus cells , RBCs ,Crystals, PH
• Uine C/S:
 Diagnostic workup

• Radiological : ~90% urinary stones radiopaque

X-ray KUB
USG
CT-KUB
IVU
Retrograde pyelography
Radioisotope scan
 Treatment

• Depends on
 Symptoms
 Size
 Location
 Complications
 Facility available
 Treatment

• Modality :
Conservative
Dissolution agents
ESWL
Endoscopic
Surgery :
Open
Laproscopic
 Treatment

• Conservative :
 < 5mm stones have 40-50% chance of spontaneous
passage
 Upper ureter : 10%
 Mid ureter : 25%
 Distal ureter : 50%
• Medical expulsive therapy (MET ):
 Hydration
 Diuretic
 Analgesic
 Alfa blockers
 Treatment

• Dissolution agents :
• Oral alkalizing agents : sodium/potassium bicabonate and
citrate, orange juice
• Intravenous alkalinization: 1/6 molar sodium lactate
• Intarenal alkalinization : sodium bicarbonate, Tromethamine
E
• For cystine stone : D-penicillamine ( 0.5%), N- acetylcystine (
2.5%), alfa- mercaptopropionylglycine ( 5%)
• Urinary acidification : for struvite stones: Suby’s G solution,
Hemiacidrin
 Treatment

• Renal stones :
ESWL
RIRS
PCNL
Open
Laproscopic
 Treatment

• ESWL :
• Indications :
 Stone < 2 cm
 Residual stone after PCNL
• Contraindications :
 Coagulopathy
 Pregnancy
 Sepsis
 Renal failure
 AAA
 Treatment

• Complications :
 Hematoma
 Hematuria
 Steinstrasse
 Treatment

• RIRS: Stone < 1.5 cm

• Indications:
– Failed ESWL
– Radiolucent stone
– Concomitant ureteric & renal stones
– Anatomic problems
– Bleeding disorders
• Complications :
– UTI/Sepsis
– Ureteric injury
– Stricture
 Treatment

• PCNL:
 Stone >2cm
 Multiple stones
 Stone in renal anomaly
 Failed ESWL
• Complications :
 Bleeding
 Sepsis
 Adjacent organ injury
 Treatment

• Surgery :
Pyelolithotomy
Extended pyelolithotomy
Nephrolithotomy
Pyelonephrolithotomy
Anatrophic nephrolithotomy
Nephrectomy
 Treatment

• Ureteral stones : sites of impaction & Rx options

 Prevention

• Hydration : fluid intake 3-4L/day

• Dietary modification:
 Avoid diet rich in calcium, oxalate, sodium, vit C
 Encourage diet rich in fibers
• Drugs :
 Allopurinol
 D –penicillamine
 Acetohydroximic acid : Urease inhibiter
• Correction of metabolic disorders :
Hyperparathyroidism, Hyperoxaluria, Hypomagnesemia
 Bladder stones

• Primary : sterile urine

• Secondary : infected urine
• C/F : Hematuria, dysuria,, suprapubic pain, UTI, urinary
retention
• Investigations : Similar to upper tract stones
• Treatment :
 Cystolitholapaxy
 Cystolithotripsy
 Cystolithotomy
 PCCL
 Treatment of underlying conditions