Renal Calculi

Nur Syafiqah, Nadiah, Siti Mariam

 Contents

01 02 03
Anatomy of Type of stone
urinary tract Aetilogy
and site
system

04 05 06
Clinical
symptoms and Investigation Management
findings
ANATOMY OF URINARY
TRACT SYSTEMS
KIDNEY A bean-shaped, reddish brown and measures
approximately 10cm in length, 5cm in width
and 2.5cm in thickness.
Lie retroperitoneally on the posterior
abdominal wall, one on each side of the
vertebral column at the level of the T12 - L3
Right kidney (T12 - L3) is slightly lowered than
left kidney (T11 - L2) due to liver

01
To filtrate and excrete waste products
from the blood.

Responsible for water and electrolyte

02
balance in the body.

03 Acid-base balance

04
Secretion of hormone-like renin,
erythropoietin and Vitamin D
External and internal features of kidney

https://www.kenhub.com/en/library/anatomy/kidneys
 Anterior Relations

Left kidney:
Right kidney:
Left suprarenal gland
Right suprarenal gland
Spleen
Right lobe of the liver
Stomach
Descending (2nd part) of
Pancreas & splenic
the duodenum
vessels
Right colic flexure
Left colic flexure
Coils of small intestine https://etc.usf.edu/clipart/54200/54263/54263_kidneys.htm
Loops of jejunum
 Posterior Relations

Right & left kidney:

Diaphragm
Psoas major, quadratus Lumborum &
transversus abdominis
Subcostal vessels & nerve, iliohypogastric &
ilioinguinal nerve
12th rib (right kidney) and 11th ribs and 12th
ribs (left kidney)

https://med.libretexts.org/Bookshelves/Anatomy_and_Physiology/Anatomy_and_Physiology_%28Boundless%29/24%3A__Urina
ry_System/24.2%3A_The_Kidneys/24.2A%3A_Location_and_External_Anatomy_of_the_Kidneys
Blood supply - Arterial supply : Renal artery
 Blood supply - Arterial supply : Renal artery

https://www.kenhub.com/en/library/anatomy/kidneys

https://courses.lumenlearning.com/suny-ap2/chapter/gross-anatomy-of-the-
kidney/
 Blood supply - Venous drainage

Right and left vein drains into inferior vena cava.

https://courses.lumenlearning.com/suny-ap2/chapter/gross-anatomy-of-the-
kidney/
URETER

constriction :
The ureters are
muscular ducts (25 - 01 Pelviureteric junction
30 cm long) with
narrow lumina
carry urine from the 02 Brim of lesser pelvis
kidneys to the urinary
bladder
diameter : 0.6cm 03 Bladder wall - as it passes through
location :
retroperitoneal organ
Blood supply
 URINARY BLADDER
A hollow viscus with strong muscular walls, is characterized by its distensibility.
A temporary reservoir for urine and varies in size, shape, position and relationships according to its
content and state of neighboring viscera.
Lies: posterior to pubic bones, on pelvic diaphragm

Empty bladder
Pyramidial in shape
superior surface is level with
superior margin of pubic
symphysis

Full bladder
Oval shape
expands superiorly into
abdominal cavity
its superior surface may reach
level of umbilicus
in direct contact with anterior
abdominal wall
 External & Internal features:

1. Mucosa
a. Mucosa is folded - rugae
b. Folds disappear when bladder is full
c. Mucosa at trigone (internal surface of fundus) always
smooth
2. Smooth muscle in wall of bladder = detrusor muscle
3. Smooth muscle at neck of bladder form internal
urethral sphincter (males only)
https://training.seer.cancer.gov/anatomy/urinary/components/bladder.html
https://quizlet.com/500949888/anatomy-1-gross-anatomy-of-urinary-system-bv-lymphatic-drainage-innervation-flash-cards/
Relations :

https://courses.lumenlearning.com/suny-ap2/chapter/gross-anatomy-of-urine-transport/
https://en.wikipedia.org/wiki/Bladder
 MALE URETHRA
A muscular tube (18-22 cm long) that conveys urine from the internal urethral orifice of the urinary
bladder to the external urethral orifice, located at the tip of the glans penis in male.
Also provides an exit for semen (sperms & glandular secretion)

Parts:

01 Intramural (preprostatic) urethra

02 Prostatic urethra

03 Membranous (intermediate) urethra

04 Spongy (penile) urethra

 FEMALE URETHRA
Short. Lies anterior to vagina
Approximately 4 cm long and 6 mm in diameter
Function: transport urine
passes anteroinferiorly from the internal urethral orifice of the urinary bladder, posterior and then inferior to
the pubic symphysis, to the external urethral orifice.
The smooth muscle surrounding the internal urethral orifice does not form the internal urethral sphincter.
The urethra passes with the vagina through the pelvic diaphragm, external urethral sphincter and perineal
membrane.

01 Short

02 Straight

03 More distensible
RENAL CALCULI / UROLITHIASIS
Stones or calculi are often formed from a mixture of chemical substances and minerals when their
concentration exceeds their solubility in urine.
Lack of crystallisation in urine may also play a role in stone formation.
They may form and become located in the calyces of the kidneys, ureters or urinary bladder.
A renal calculus may pass from the kidney into the renal pelvis and then into the ureter.
If the stone is sharp or larger than the normal lumen of the ureter which is approximately 3mm, it
may cause excessive distension of this muscular tube.
 CaOx& CaP

CaP

https://www.stone-relief.com/calcium-phosphate-kidney-stones/#type-iva1-cap-stones

Uric acid
Cysteine
http://www.emdocs.net/em3am-urolithiasis/
https://www.healthhub.sg/a-z/diseases-and-conditions/kidney-stones
 AETIOLOGY
1. Idiopathic calcium urolithiasis
2. Hypercalcaemic disorders
Primary hyperparathyroidism:
Overproduction of PTH -> Synthesis of 1,25-
dihydroxycholecalciferol -> Increased
intestinal calcium absorption, renal tubular
reabsorption and bone resorption.
Prolonged immobilisation:
Prolonged recumbency, paralysis leads to
bone atrophy. Osteoclast-activating
cytokines or prostaglandins stimulate
osteoclast to resorb bone.
Milk-alkali Syndrome:
Characterised by a triad of elevated calcium levels,
metabolic alkalosis and acute kidney injury. Commonly
due to intake of large amounts of calcium and
absorbable alkali that may result in hypercalcaemia,
alkalosis and possible renal impairment.
Sarcoidosis:
Small patches of swollen tissue, called granulomas.
This granuloma produces 1,25-dihydroxycholecalciferol.
 3. Renal Tubular Syndromes
Renal Tubular Acidosis (RTA):
Due to hypercalciuria and low urinary citrate
excretion
Cystinuria:
This results from an inherited defect (autosomal
recessive) of amino acid transport in renal tubules
and the gastrointestinal tract involving cystine,
ornithine, lysine and arginine (COAL or COLA).
4. Uric Acid Lithiasis
Uric acid is an end-product of purine
metabolism. Dietary purine and protein
excesses may increase urinary uric acid
excretion.
Uric acid stones can also occur in patients
with normal serum uric acid levels
(idiopathic uric acid lithiasis)
Secondary Urolithiasis
Dietary Excess:
Rhubarb, spinach, tea, cocoa, chocolate and pepper
commonly increase urinary oxalate
Infection:
Urease-producing organisms, e.g. Proteus, Pseudomonas
and Staphylococcus, break down urea to produce
ammonia and CO2. The urine becomes alkaline which
promotes formation of struvite calculi (magnesium
ammonium phosphate) which can grow to form a staghorn
calculus.
Other factors:
Hot environment, low water intake, diet
Obstruction and Stasis:
Delayed crystal washout leads to aggregation
and stone formation.
Drugs:
Acetazolamide stimulates renal tubular
acidosis. Allopurinol may precipitate xanthine
stones. Thiazide diuretics can result in uric
acid stone formation.
Sites of stone:
Nephrolithiasis

1. Calyceal stone
Kidney stones in minor and major calyces of kidney
Asymptomatic. It can cause ureteric colic in case of migration.
The decision for an active treatment of caliceal calculi is based on
stone composition, stone size and symptoms.

2. Renal pelvic stone

Stones are in the pelvis of kidney.

3. Staghorn kidney stone

In renal pelvis and at least one renal calyces.
Commonly, composed of struvite (magnesium ammonium phosphate).
Untreated staghorn calculus is likely to destroy the kidney or causing
life-threatening infections (sepsis)
SITES OF STONE:
Urolithiasis

1. Pelvi-ureteric junction stone (PUJ)

PUJ obstruction is usually congenital (ureteral hypoplasia, high insertion of ureter,
entrapment of ureter by renal vessels)
May also be acquired (compressed by blood vessels, inflammation, stone, scar tissue).
Complication: Hydronephrosis
May be noticed on ultrasound scan during pregnancy (Antenatal hydronephrosis)
Management: Pyeloplasty

2. Ureteric stone
Kidney stones that stuck in the ureter

3. Vesico-ureteric junction stone (VUJ)

VUJ obstruction is usually congenital and may be acquired (scar tissue, infection, benign
polyp or kidney stones).
Congenital: Problem with the development of muscular wall of ureter.
Complication: Hydroureteronephrosis
Symptoms of Kidney Stones

1. Unilateral and colicky flank pain (renal colic).

2. Radiates anteriorly to the lower abdomen, groin, labia,
testicles or perineum.
3. Cloudy urine
4. Foul smelly urine
5. Hematuria
6. Urinary Frequency
7. Dysuria
8. Nausea and vomiting

*Depending on the location of the stone,

nephrolithiasis may resemble conditions
such as appendicitis or testicular torsion.
Presentation depends on sites:
1. Renal stone:
Most often asymptomatic

2. Ureteric stone:
Ureteric colic pain: severe, intermittent loin to groin pain
Hematuria
Fever- Urinary tract infection
Urinary frequency, urinary urgency and dysuria: If the stone at VUJ

3. Bladder stone:
Suprapubic pain
Can cause irritative urinary symptoms: Urinary frequency and urgency
Pain or discomfort in the penis
Inability to urinate except in certain positions
Interruption of the urine stream
Hematuria
Dysuria
Fever
 INVESTIGATION

IMAGING
LABORATORY
1. KUB X Ray
1. Haematological Tests
2. IV Pyelogram
2. Urine tests 3. Ultrasound
4. CT Scan

OBJECTIVES OF INVESTIGATIONS
1. To confirm the presence of stones
2. To determine the location of stone
3. To evaluate the effect of stones on renal function and urinary tract
morphology
4. To identify any metabolic predisposing factor
 Laboratory investigation
blood test

full blood count renal function test

Na & K
WBC electrolyte imbalanced
infection
due to kidney injury
Hb
Uric acid
RBC uric acid stone
anemia

Platelet calcium
metabolic disorder :
hyperparathyroidism
 Laboratory investigation
urine test

1. dipstick
2. urine culture/sensitivity complete urinalysis consists of 3 components

3. 24 H urine collection
 Diagnostic imaging
plain X- ray kidney
ureter bladder (KUB)

opacity likely to be a calculus

Aid in detection of calcified stone :
location,size,shape and composition

➔ Helpful in differentiating between

radiopaque and radiolucent stones
➔ Used in the follow -up of a patient
who is expected to pass a stone
spontaneously
 Diagnostic imaging
non -contrast enhanced CT

➔ Can detect over 90% of stones

➔ CT scan of abdomen and pelvis
can detect hydronephrosis and
demonstrates the best
diagnostic performance for
nephrolithiasis
 Diagnostic imaging
IV Urography

➔ To detect urinary tract

obstruction secondary to urolithiasis
➔ Involves administration of intravenous
contrast and x-ray imaging of the urinary tract
➔ Useful in the evaluation of hematuria,renal
stone disease and follow-up intervention
 Diagnostic imaging
ultrasound scanning

➔ Able to assess kidney size,signs

of injury,presence of stone and any
dilatation of collecting system
has a lower sensitivity and
specificity than CT, but does
not require use of radiation
 Size and location of the stone determine management
>10 mm and/or in the proximal ureter
These patients usually require intervention and should be referred to urology.

Stones >5 and 10 mm

These patients are suggested for MET to facilitate stone passage.

Stones 5 mm
These typically do not require specific treatment; most will pass spontaneously

MEDICAL
management
1. Medical Expulsive Therapy
2. Xanthine oxidase inhibitor
3. Conservative management

SURGICAL
1. Percutaneous Nephrolithotomy (PCNL)
2. Extracorporeal Shock Wave Lithotripsy (ESWL)
3. Ureteroscopy (URS)
4. Pyelolithotomy
 MEDICAL

Medical Expulsive Therapy (MET) Xanthine oxidase inhibitor

Conservative management

➔ pain control, ➔ use of medication to facilitate ➔ clinical management of gout

hydration,medical ureteral stone passage prior to and conditions associated with

expulsive therapy surgical intervention hyperuricemia

acetaminophen and a alpha-blockers and calcium to prevent uric acid stones.

channel blockers. Allopurinol
nSAIDS
tamsulosin and nifedipine
 SURGICAL

Extracorporeal Shock Wave Lithotripsy (ESWL)

➔ breaks down stones in parts of the urinary

system, in the pancreas and in the bile ducts

Stones in the kidneys and ureter often

Used to treat small- to medium-sized kidney

stones

Contraindicated in patients with obesity,who

are pregnant, or with a bleeding diathesis.

 SURGICAL

Ureteroscopy (URS)

➔ Transurethral endoscopic visualization of the upper urinary tract with a rigid or

flexible endoscope used for stone extraction and intraureteral lithotripsy

(minimally invasive)

Commonly combined with temporary ureteral stenting

The treatment of choice for the majority of middle and distal ureteral stones

and can also be used to manage proximal ureteral and kidney stones.

Frequently useful for the management of ureteral stones that have failed SWL

The modality of choice for patients with obesity, with hard stones, pregnant

or have a bleeding diathesis.

 SURGICAL

Percutaneous Nephrolithotomy (PCNL)

➔ Percutaneous insertion of a nephroscope into the renal pelvis

under ultrasonographic and/or fluoroscopic guidance to remove
stones (minimally invasive)
● Can be combined with lithotripsy
● More effective than SWL or URS for most
stones
● large or complex stones or unsuccessful attempts of SWL and
URS
stones >20mm or staghorn stones
 OPEN SURGERY

Extended
Pyelolithotomy Pyelolithotomy
THANK YOU!
refferences:

1. Browser's introduction to the

symptoms and signs of surgical disease
2. Bailey and Love, Principle and Practise
of Surgery 25th Edition
3. Essential Surgery : problems, diagnosis,
management, 5th edition