URINARY LITHIASIS

TEKLEBERHAN BERHE,MD
Introduction
Urinary stones have afflicted human kind since antiquity
The first record of urinary calculi were bladder and kidney
stones detected in Egyptian mummies dated to 4800
BC.The speciality of urologic surgery was recognized by
Hippocrates who wrote, in his famous oath for the
physician, "I will not cut, even for the stone, but leave
such procedures to the practitioners of the craft"
The prevalence is estimated to be 2-3% and the likelihood
that a person will develop stone disease by age 70 is about
1in 8.
The peak incidence of urinary calculi is from twenties to
forties
About 3males are afflicted for every female.
 PATHOGENESIS OF RENAL CALCULI
The aetiology is speculative and basic
mechanisms of stone formation unknown.
METABOLIC ABNORMALITIES
 Stones form in the urine when solute
concentration reach super-saturation and this is
likely to occur at low urine volume.
This tendency to crystallization is exacerbated
by diseases which result in excess urinary
excretion of solute such as
calcium,oxalate,aminoacids(eg.Cystine) or
 PATHOGENESIS OF RENAL CALCULI
Continued.....
In addition there are naturally occurring inhibitors of
crystallization in the urine(Citrate,pyrophospahtes &
magnesium) which may be deficient in stone formers.
Matrix deposition may be the precursor of stone formation.
 ANATOMIC ABNORMALITIES-abnormalities of
microanatomy have been proposed.
Theory-kidneys of patients who form stones posses areas of
sub epithelial papillary calcification (Randall’s plaques) on
which solutes crystallize to form micro-calculi.These
plaques then slough off into the collecting system to form
the nucleus of large stones.
PATHOGENESIS OF RENAL
CALCULI

Endoscopic images of Randall plaques in calcium oxalate patients. sites of

Randall’s plaques (arrows) appear as irregular white areas beneath the urothelium.
 PATHOGENESIS OF RENAL CALCULI
Continued.....
URINARY INFECTION
Typically infective stones are large ‘staghorn’calculi
made of Struvite(calcium,magnesium,ammonium
phosphates).They are formed by the action of
enterobacterius usually Proteus which produce an
enzyme urease that splits urinary urea to form
ammonium ions resulting in a rise in urinary PH.
IDIOPATHIC STONE FORMATION
In 5-10% of all stone formers no abnormality can be
found to account for the stone forming tendency
Major risk factors
 The aetiology of urinary calculi is multifactoral and rarely can a single
factor in the patient's history account for the presence of stone.
Therefore a detailed history should be taken.
 Diet & fluid intake-
 Medications –steroids, loop diuretics, chemotherapeutics,
 Infections-UTI with urease producing bacteria
 Activity levels-periods of immobilization may lead to bone
demineralization and hypercalciuria
 Systemic diseases like primary hyper parathyroidism,renal tubular
acidosis, gout
 Genetics-The history of a family member having stone disease
increases the likelihood of recurrences fourfold.
 Anatomy-urinary tract obstruction-congenital(PUJ obstruction or
horseshoe kidney) or acquired(BPH,urethral stricture) lead to urinary
stasis and stone formation.
 TYPES OF STONES
CALCIUM SALTS,URIC ACID,CYSTINE AND STRUVITE ARE THE
BASIC CONSTITUENTS OF MOST KIDNEY STONES.
 CALCIUM STONES-most stones are composed of calcium
salts(Oxalate or phosphate)
 most are idiopathic
Stones are very hard and radio opaque.
 URIC ACID STONES-
Uric acid lithiasis is usually familial
 Half of patients with such stones have gout
Are radiolucent.
 CYSTINE STONES-Are uncommon
Occurs in patients with congenital error of metabolism that leads to
cystinuria
Are radio-opaque due to the sulphur they contain.
Continued...
 STRUVITE
STONES(calcium,ammonium,magnesium
phosphate ‘triple phosphate’)
Stones tend to grow in alkaline urine and
occur mainly in women with UTI
Stones can grow to a large size and fill the
renal pelvis and calyces to produce ‘stag
horn' appearance.
They are radio opaque.
Examples of urinary calculi
 CLINICAL MANIFESTATIONS
Symptoms are variable and diagnosis sometimes obscure.
Silent stones-patients may occasionally be diagnosed with
asymptomatic calculi when radiograph is done for other purposes
or may present after passing gravel or a stone.
PAIN (renal colic)is the most common symptom and varies from
mild to intense discomfort.
Pain is thought to occur primarily from urinary obstruction with
distension of the renal capsule.
 The site of obstruction determines the location of pain.
 Upper ureter or pelvis----flank pain

Lower ureter-----pain that radiates to the epsilateral testicle or

labium.
 The severity of pain is not related to the size of the stone.
 The celiac ganglion serves both the kidney and stomach;therfore
nausea or vomiting are commonly associated with renal colic.
 CLINICAL MANIFESTATIONS Continued....
HEMATURIA
 Gross or microscopic hematuria may occur in majority of
patients and even, it may be the only presenting complaint.
PYURIA-Infection is likely in the presence of stones.
OTHERS
 When ureteral stones are near the bladder, patients often develop
symptoms of urgency and frequency.
PHYSICAL SIGNS
 Individuals with urinary lithiasis can rarely find comfort in any
position. they sit,stand,pace,and recline in an attempt to ‘shake
off 'whatever that is creating discomfort.
 Fever is not present unless there is UTI along with the stone.
 PR and BP may be elevated because of pain& to agitation.
 Exam of the abdomen reveals moderate tenderness over the area
complications
Nephrolithiasis may lead to persistent renal
obstruction which could cause permanent
renal damage if left untreated.
DIFFERENTIAL DIAGNOSIS
Ectopic pregnancy
Renal cell carcinoma with bleeding
Acute appendicitis
Acute cholecystitis
 DIAGNOSIS
HISTORY&PHYSICAL EXAM
CBC,CHEMISTRY PANEL,URINALYSIS
RADIOLOGICAL TESTS
KUB
Will identify radio-opaque stone such as calcium struvite and
cystine but miss radiolucent stones, small stones or stones
overlying bony structures
IVU
Have higher sensitivity and specifity than KUB and provides
data about degree of obstruction
ULTRASOUND
Procedure of choice for patients who should avoid radiation,
including pregnant women, can detect radiolucent stones
DIAGNOSIS continued
Computed tomography—
Noncontrast spiral CT scans are now the imaging
modality of choice in patients presenting with acute
renal colic.
It is rapid and is now less expensive than an IVP.
It images other peritoneal and retroperitoneal
structures and helps when the diagnosis is uncertain.
It does not depend on an individual
 There is no need for intravenous contrast
Radio-densities of renal calculi
LOWER POLE KIDNEY STONE
 MANAGEMENT
 ACUTE THERAPY
Pain control with NSAID and hydration-most patients pass stones
spontaneously
Calculi <4mm wide have >90% chance of passing stones, where as
stones >6mm have 10% chance of spontaneous passage.
 RENAL&PROXIMAL URETERAL STONE-ESWL
 Stag horn calculi—percutaneous nephrolithotripsy
 MID URETERAL STONES-Stone retrieval using wire basket or
uretroscope
 DISTAL URETERAL STONES-ureteroscopic removal,ESWL
 SURGERY(Pyelolithotomy,Nephrolithotomy,Ureterolithotomy)
Needed when appropriate expertise is not available, or when the new
techniques failed to clear calculus.
Complex stones with associated anatomic abnormalities.
 Medical management
Prevention of recurrence
The evaluation of recurrent stone formers
or high risk stone formers(patients with
family history of stone disease or medical
conditions, chronic UTI,histroy of gout )is
indicated.
A simplified evaluation includes a careful
history, a serum chemistry
profile,urinalysis,plain radiograph and
 Bladder stones
Usually originates in the kidney (primary)but others may occur in the
presence of infection,BOO,or a foreign body(secondary).
Most common among the poor and in children.
Males are affected 8 times more than women
SYMPTOMS
Pain(strangury),frequency,hematuria,inturuption of urinary stream
The stone is visible on radiography
Endoscopy is essential
TREATMENT
Eradication of obstruction, correction of bladder stasis, and removal
of foreign bodies reduces recurrence.
OPTICAL LITHOTRITE
SURGERY