Urolithiasis

Dr. Ahmad Kharrouby

Urology Specialist
Urolithiasis

Urolithiasis (from Greek oûron-urine and lithos-stone) is

the condition where urinary stones are formed or located
anywhere in the urinary system.
Background
Urolithiasis

 Kidney stones
 Ureteral stones
 Bladder stones
 Urethral stones
Background
 Urolithiasis is a common
disease that is estimated to
produce medical costs of $2.1
billion per year in the United
States alone.
 Urolithiasis has been a part of
the human condition for
millennia and have even been
found in Egyptian mummies.
Background
 Renal colic affects approximately 1.2 million people
each year in USA and accounts for approximately 1% of
all hospital admissions.
 Most active emergency departments (EDs) manage
patients with acute renal colic every day
Epidemiology
Epidemiology
 Urolithiasis occurs in all parts of the world
 A lifetime risk:
 2-5% for Asia
 8-15% for the West
 20% for the Kingdom of Saudi Arabia
 Hot Climate

 Dietary habits

 Hereditary factors
 Epidemiology
 The lower the economic status, the lower the likelihood
of renal stones
 Most at 20-49 years
 Peak incidence at 35-45 years
 Male-to-female ratio of 3:1
Chemical types and etiology
 Chemical Types

 Four main chemical types:

 Calcium stones
 Struvite (magnesium ammonium phosphate) stones
 Uric acid stones
 Cystine stones
Calcium stones
 Calcium stones
account for 75%
of Urolithiasis.
 Radio-opaque

 Multiple factors

and etiologies
 Mostly incidental
Calcium Stone Known
etiologies
 Incidental
 Hyperparathyroidism
 Increased gut absorption of calcium
 Renal calcium leak
 Renal phosphate leak
 Hperuricosuria
 Hperoxaluria
 Hypocitraturia
 Hypomagnesuria
Calcium Stone
Struvite (magnesium ammonium
phosphate) stones
 Account for 15% of renal calculi
 Infectous stones
 Gram-negative rods capable of
splitting urea into ammonium, which
combines with phosphate and
magnesium
 More common in females
 Urine pH is typically greater than 7
Struvite (magnesium ammonium
phosphate) stones

 Stag horn stones

are non
obstructive thus
painless
 Slowly growing

 Discovered

incidentally
Uric acid stones
 Account for 6% of renal
calculi
 Urine pH less than 5.5
 High purine intake eg.

 organ meats
 legumes

 malignancy
 25% of patients have gout
Uric Acid Stones
Uric Acid Stones
Cystine stones
 2% of renal calculi
 Autosomal recessive trait
 Intrinsic metabolic defect resulting in
failure of renal tubular reabsorption of:
 Cystine
 Ornithine
 Lysine
 Arginine
 Urine becomes supersaturated with
cystine, with resultant crystal
deposition
Cystine Stones
 Radio-faint
Prognosis
Prognosis
 80 % pass spontaneously
 20% require hospital admission or intervention because
of:
 unrelenting pain
 inability to retain enteral fluids
 proximal UTI
 inability to pass the stone
 renal failure
Prognosis

 Recurrence rates after an initial episode of

ureterolithiasis:

 14% at 1 year
 35% at 5 years
 52% at 10 years
History
 History

The presentation is variable.

 Patients with urinary calculi may report

 Pain
 Infection
 Hematuria
 Asymptomatic
Silent Kidney stones

 Small nonobstructing stones in

the kidneys only occasionally
cause symptoms.
 If present, symptoms are usually
moderate and easily controlled.
 Obstructive ureteral stone

 The passage of stones into

the ureter is associated with
classic renal colic because
of:
 subsequent acute obstruction
 proximal urinary tract dilation
 ureteral spasm
 Acute renal colic is probably
the most excruciatingly
painful event a person can
endure
 Classic Renal Colic

 Acute onset of severe flank pain radiating to the groin

 Gross or microscopic hematuria
 Nausea, and vomiting not associated with an acute abdomen in
50%
 Staghorn stone

 Staghorn calculi are often

relatively asymptomatic.
 Branched kidney stone occupying
the renal pelvis and at least one
calyceal system.
 Manifest as infection and
hematuria.
Acute renal failure

 Asymptomatic bilateral
obstruction
 Solitary Kidney with
obstructive stone
Location and characteristics of
pain from ureteral stones
 Depends on the level of
obstruction and its degree:
 ureteropelvic junction
 pelvic brim
 ureterovesical junction
UPJ Stone

 Stones obstructing the

ureteropelvic junction may
present with mild-to-severe
deep flank pain without
radiation to the groin
Ureteral Stone

 Cause abrupt, severe, colicky pain in the flank and

ipsilateral lower abdomen
 with radiation to the testicles or the vulvar area.
 Intense nausea, with or without vomiting, usually is
present.
Upper ureter

 Tends to radiate to the

flank and lumbar
areas
Mid Ureter
 Cause pain that radiates anteriorly and caudally.
 Can easily mimic appendicitis on the right or acute
diverticulitis on the left.
Distal Ureter and UVJ stones

 Cause pain that tends to radiate into the groin or testicle

in the male or labia majora in the female
 At the ureterovesical junction also may cause irritative
voiding symptoms mimicking cystitis, such as:
 urinary frequency
 dysuria
Pain distribution review
Bladder Stones

 Usually asymptomatic and are passed relatively easily

during urination.
 Rarely, a patient reports positional urinary retention
(obstruction precipitated by standing, relieved by
recumbency).
Phases of an attack
Phases of an attack

The entire process typical lasts 3-18 hours

Acute phase: peak in most patients within 2 hours of onset (30 min to 6
hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 1.5-3 hours
Physical exam
Physical exam
 Dramatic costovertebral angle
tenderness
 unremarkable abdominal evaluation
 painful testicles but normal-appearing
 constant body positional movements
(eg, writhing, pacing)
 Tachycardia
 Hypertension
 Microscopic hematuria
Diagnosis
Diagnosis
 The diagnosis of nephrolithiasis is often made on the
basis of clinical symptoms alone, although confirmatory
tests are usually performed.
Laboratory tests
Labarotary Testing
 The recommended based on EUA recommendations:

 Urinary sediment/dipstick test: To demonstrate blood cells

 Serum creatinine level: To measure renal function
Additional Lab Tests
 May be helpful:
 CBC in febrile patients
 Serum electrolyte assessment in vomiting patients
 24-Hour urine profile on outpatient basis
Imaging studies
Imaging studies
 Noncontrast abdominopelvic CT scan: The imaging
modality of choice for assessment of urinary tract
disease, especially acute renal colic.
 IV contrast and delayed images might be required in
selected cases
Imaging studies
 Renal ultrasonography:
 Renal stone
 Hydronephrosis or ureteral dilation
 Misses 30 % of stones
 Plain abdominal radiograph (flat plate or KUB) misses
40 % of stones
Imaging studies

 IVP (urography) historically, the criterion standard

 In rare select situations:

 Plain renal tomography

 Retrograde pyelography

 Nuclear renal scanning

Management
 Emergency Renal Colic

 IV access to allow :
 Fluid
 Analgesics:
 Paracetamol

 NSAID

 Opiod

 Antiemetic
 In case of infection:
 Urine culture
 Blood culture accordingly e.g. febrile
 Antibiotics
 Approach Considerations

 In emergency settings what should be kept in mind is the

small percentage suffering renal damage or sepsis.
 These include:

 Evident infection with obstruction

 A solitary functional kidney
 Bilateral ureteral obstruction
 Renal failure
 Important

 The most morbid and potentially dangerous aspect of

stone disease is the combination of urinary tract
obstruction and upper urinary tract infection.
 Pyelonephritis
 Pyonephrosis
 Urosepsis
 Early recognition and immediate surgical drainage are
necessary in these situations
Approach Considerations

 The size of the stone is an

important predictor of
spontaneous passage.
 A stone less than 4 mm in
diameter has an 80%
chance of spontaneous
passage; this falls to 20%
for stones larger than 8 mm
in diameter
Approach Considerations
 Hospital admission is clearly necessary when any of the
following is present:
 Oral analgesics are insufficient to manage the pain.
 Intractable vommiting
 Ureteral obstruction from a stone occurs in a solitary or
transplanted kidney.
 Bilateral ureteral obstruction
 Ureteral obstruction from a stone occurs in the presence of
 a urinary tract infection (UTI)
 Fever
 Sepsis
 Pyonephrosis
Approach Considerations

 Relative indications to consider for a possible admission

include comorbid conditions
 diabetes
 dehydration
 renal failure
 immunocompromised state
 perinephric urine extravasation
 pregnancy
Approach Considerations

Most patients with acute renal colic can be treated on an

ambulatory basis.
Approach Considerations

 Aggressive medical therapy has shown promise in

increasing the spontaneous stone passage rate and
relieving discomfort while minimizing narcotic usage
 Clinic Follow up

 Patients who do not meet admission criteria to be

discharged on medical expulsive therapy from the ED in
anticipation that the stone will pass spontaneously at
home.
 Arrangements should be made for follow-up with a
urologist in 2-3 days.
Active medical expulsive therapy

 Paracetamol PRN for pain with or without Codeine

 NSAID PRN for pain
 Oral opiod analogue for severe pain
 Alpha blockers
 Antiemetic PRN for nausea and/or vommiting
 Prednisone 20 mg twice daily for 6 days

 With MET, stones 5-8 mm in size often pass, especially if

located in the distal ureter.
Approach Considerations

 An important aspect of medical and preventive therapy is

maintaining a good fluid intake and subsequent high
urinary volume.
 Emergency Advice

 Patients should be told to return for :

 fever

 uncontrolled pain

 uncontrolled vomiting

 Patients should be discharged with a urine strainer and

encouraged to submit any recovered calculi to a urologist
for chemical analysis
Approach Considerations

 General recommendation not to wait longer than 4

weeks for a stone to pass spontaneously before
considering intervention.
Approach Considerations

 Larger stones (ie, ≥ 7 mm) that are unlikely to pass

spontaneously require some type of surgical procedure.
 Such patients require mandatory urology follow up
Approach Considerations

 About 15-20% of patients require invasive intervention

eventually as emergency or electively due to:
 stone size
 continued obstruction
 Infection
 intractable pain
 Indications for Surgery

 The primary indications for surgical treatment include:

 Pain
 Infection
 Obstruction

 Indications for urgent intervention:

 Obstruction complicated by evident infection

 Obstruction complicated by acute renal failure

 Solitary kidney

 Bilateral obstruction
 Surgical options

 Obstruction relief:
 Ureteral stent insertion
 Percutaneous nephrostomy
 Definitive surgical treatment:
 ESWL
 Ureteroscopy
 PCNL
 Open, laparoscopic and robotic
pyelo-lithotomy, ureterolithotomy,
cystolithotomy
 Open anatrophic nephrolithotomy
 Surgical options

 For an obstructed and infected collecting system

secondary to stone disease
 Emergency surgical relief is required with no contraindications:
 percutaneous nephrostomy for critical patients

 ureteral stent placement for stable patients

Surgical options

 The vast majority of symptomatic urinary tract calculi are

now treated with noninvasive or minimally invasive
techniques
 Open surgical excision of a stone from the urinary tract is
now limited to isolated atypical cases
Surgical options

 ESWL and ureteroscopy are internationaly recognized as

first-line treatments for ureteral stones.
 The 2005 American Urological Association (AUA)
staghorn calculus guidelines recommend percutaneous
nephrostolithotomy as the cornerstone for management
 Ureteral Stent

 Guarantees drainage of urine from

the kidney into the bladder and
bypass any obstruction.
 Relieves renal colic pain even if the
actual stone remains.
 Dilate the ureter, making
ureteroscopy and other endoscopic
surgical procedures easier to
perform later.
 Percutaneous nephrostomy

 Indicated if stent placement is

inadvisable or impossible.
 In particular patients with
pyonephrosis who have a UTI or
urosepsis exacerbated by an
obstructing calculus
 Extracorporeal shockwave
lithotripsy
 ESWL, the least invasive of the
surgical methods of stone
removal
 Utilizes an underwater energy
wave focused on the stone to
shatter it into passable fragments
 It is especially suitable for stones
that are smaller than 2 cm and
lodged in
 the upper or middle calyx

 the upper ureter

 Extracorporeal shockwave lithotripsy

 The patient, under varying degrees of anesthesia

 The shock head delivers shockwaves developed from an
 Electrohydraulic

 Electromagnetic

 piezoelectric source
 Ureteroscopy

 Ureteroscopic manipulation of a
stone is a commonly applied
method of stone removal
 A small endoscope, which may be
 Rigid
 Semirigid
 Flexible
 is passed into the bladder and up
the ureter to directly visualize the
stone
 Ureteroscopy

 Flexible ureteroscopy allows tackling

of even lower calyceal stones
 Stones are fragmented using
 Swiss lithoclast
 Laser
 Ultrasonic lithotripter
 Stones are retrieved using a stone
basket
Percutaneous nephrostolithotomy

 Percutaneous procedures are generally reserved for

large and/or complex renal stones and failures from the
other 2 modalities
 Percutaneous nephrostolithotomy is especially useful for
stones larger than 2 cm in diameter
Percutaneous nephrostolithotomy

 In some cases, a combination

of SWL and a percutaneous
technique is necessary to
completely remove all stone
material from a kidney.
 Open Surgery

 Open surgery has been used less

and less often since the
development of the previously
mentioned techniques
 It now constitutes less than 1% of
all interventions.
 Disadvantages include
 longer hospitalization
 longer convalescence
 increased requirements for blood
transfusion.
Approach Considerations

 Metabolic evaluation and treatment at clinic are indicated

for patients at greater risk for recurrence, including:
 multiple stones
 personal or family history of previous stone formation
 stones at a younger age
 residual stones after treatment
Medical Therapy for Stone Disease

 Urinary calculi composed predominantly of calcium

cannot be dissolved
 medical therapy is important in the long-term
chemoprophylaxis of further calculus growth or formation
Medical Therapy for Stone Disease

 Uric acid and cystine calculi can be dissolved with

medical therapy.
 Suitable option in patients with uric acid stones who do
not require urgent surgical intervention
 Is based on alkalization of the urine.
Medical Therapy for Stone Disease

 Sodium bicarbonate can be used as the alkalizing agent

 But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a
high sodium load
Medical Therapy for Stone Disease

 The dosage of the alkalizing agent should be adjusted to

maintain the urinary pH between 6.5 and 7.0.
 Chemoprophylaxis

 Prophylactic therapy might include:

 most importantly, augmentation of fluid intake.
 limitation of dietary components
 addition of stone-formation inhibitors or intestinal calcium binders
 avoid excessive salt and protein intake
Chemoprophylaxis

Better to base medical therapy for long-term

chemoprophylaxis of urinary calculi on the results of a
24-hour urinalysis for chemical constituents
 Long-Term Monitoring
 Metabolic evaluation is done by a typical 24-hour urine
determination of:
 urinary volume
 pH
 specific gravity
 Calcium
 Citrate
 Magnesium
 Oxalate
 Phosphate
 uric acid.
 Long-Term Monitoring

 Most common findings are

 Hypercalciuria

 Hyperuricosuria

 Hyperoxaluria

 Hypocitraturia

 low urinary volume

 Chemoprophylaxis

 Chemoprophylaxis of uric acid and cystine calculi

consists primarily of long-term alkalinization of urine.
Chemoprophylaxis

If hyperuricosuria or hyperuricemia is documented in

patients with pure uric acid stones, allopurinol (300 mg
qd) is recommended
 Chemoprophylaxis

 Pharmaceuticals that can bind free cystine in the urine:

 D-penicillamine
 2-alpha-mercaptopropionyl-glycine
 Help reduce stone formation in cystinuria.
 Captopril has been shown to be effective in some trials
 Dietary Measures

 In almost all patients in whom stones form, an increase in

fluid intake and, therefore, an increase in urine output is
recommended.
 This is likely the single most important aspect of stone
prophylaxis
 The goal is a total urine volume in 24 hours in excess of
2 liters.
 Dietary Measures

 The only other general dietary guidelines are to avoid

excessive salt and protein intake.
 Moderation of calcium and oxalate intake is also
reasonable
 Beware to advice moderation not avoid calcium intake as
it will result in calcium deficiency disorders, most
importantly osteoperosis.
Thank you
References

• Main references:
• Medscape article nephrolithiasis by J Stuart Wolf Jr, MD, FACS updated
feb 11, 2013
• Campbell-Walsh Urology 10th edition
• Smith and Tanagho's General Urology, Eighteenth Edition

• Images used in this presentation are from different web

based resources
• N.B. The presentation is directed to general medical
audience in the hospital mainly nurses and physicians
with special focus on the acute management.