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UROLITHIASIS

Savenkov V. I.

Epidemiology:
Intrinsic Factors
• Hereditary [runs in families]
• age “all ages susceptible, in elderly male – BPH ”
• Sex, M:F = 3:1 due to male anatomy
Extrinsic Factors
• Geography [equator]
• Colder areas  tendency to form stones
• Climate & seasonal factors
• Water intake
• Oxalate-rich diet [tomato, mangoes, tea,
strawberry]
• Occupation

uric acid. physical changes in urine: – ↓ urine volume w/ N calciuria →↑ conc. hypersecretion of relatively insoluble urinary constituents e. Etiology of Urinary Stones: • 1. oxalates.Uric acid . hypercalciuria.Ca carbonate • . phosphates. of Ca – Urinary Mg : Ca ratio – Urinary pH • Acidic Alkaline • .Mg ammonium sulfate . cystine…etc • 2.Ca phosphate • .g.Oxalate .

nucleus formation • 4. Cont… • 3. structural abnormalities of the urinary tract [obstruction] The ureters have 3 narrow points where stones are usually found: • Pelvi-Ureteric Junction – PUJ • Pelvic inlet “crossing iliac vessels” • uretero-vesical junction .

Renal Calculi DEFINITION: • A renal calculi is a solid mass that consists of collection of tiny crystals. • There can be one or more stones present at the same time in the kidney or in the ureter or bladder .

clot due to trauma to kidneys or much Hemoglobinuria • .pus • .papilla in papillary necrosis • 3. ↑ concentration of solutes • 2. Factors affecting Stone Formation • 1. nucleus • .foreign body • . stagnation “obstruction” .

triamterene …etc) .8-dihydroxyadenine •Silica •Insoluble drugs (eg indinavir. Composition of Renal Calculi MINERAL (90%) WATER ORGANIC (7%) MATRIX (3%) •Calcium oxalate •Mucoprotein •Calcium phosphate •protein •Magnesium ammonium phosphate •Uric acid •Cystine •Xanthine •2.

due to in-born errors of metabolism” • Cystinuria • Hyperoxaluria • Hyperparathyroidism • Idiopathic hypercalciuria • Xanthinuria . Classification of Urinary Stones: Primary “Metabolic Stones.

Classification of Urinary Stones: Secondary “non-metabolic stones” • Infection stones in alkaline urine • Dehydration • Urinary obstruction • Immobilization as result of: – Bone resorption & demineralization of bone & hypercalciuria – Stagnation of urine .

Retention of critical – sized particle 4. Growth of trapped particle . Crystal nucleation 2. Crystal growth and agglomeration 3. Urinary stone formation Free-particle model 1.

Stone formation Urine containing crystals flowing down collecting tubules Free. Fixed- particle particle model of Crystal growth model of stone and stone agglomeration initiation initiation Critical particle trapped in tubule Particle adheres to damaged site on tubule wall and other crystals agglomerate with it .

Types of renal stone • Calcium oxalate 75% • Magnesium ammonium phosphate 10-15% • Uric acid 6% • Cystine 1-2% .

OXALATE • It is end product of endogenous amine acid metabolism • Urinary concentration variable • (150-450 mmol/day) .

STRUVITE • Struvite stone form in infected urine • pH is high >7 • Bacteria urease • Urea ammonia ammonium • Large (staghorn) calculi which may obstruct the KUB .

URIC ACID STONES • End product of purine metabolism • Solubility in urine pH dependent • Normal excretion (500-600 mg/day) .

CYSTINE STONES • Mainly formed from the amino acid cystine • These stones can be dissolved slowly with maintenance of high fluid intake (5l/day) • Intake of penicillamine which causes cystine to be converted to more soluble penicillamine cystine .

Staghorn Stone • Stone filling the pelvis with one or more of the major calyces • Complain late because it doesn’t cause urinary obstruction .

Renal Colic: • colicky pain starting from the costo- vertebral angle [renal angle] radiating to the front to the lumbar & iliac fossa & genitalia of the same side • flank pain “due to stretching of the kidney capsule” .

Diagnosis • 85% of stones are radio-opaque • KUB. plain X ray for radio-opaque stones • US for radiolucent + radio-opaque • IVU • Retrograde Pyelogram • CT • MRI • Isotope renal scan .

EFFECTS AND COMPLICATIONS • Renal colic • Hematuria • Obstruction • Infection • Stricture • Squamous metaplasia .

Complications in nephrolithiasis • Acute pyelonephritis • Chronic calculous pyelonephritis • Calculous pyonephrosis • Calculous hydronephrosis • Nephrogenic arterial hypertension • Acute renal insufficiency • Chronic renal insufficiency .

Treatment • Medical • Interventional • Prevention of Recurrence .

Medical Treatment Aim: • dissolve stone • help it to pass Dissolving stones: – Any radio-opaque stone doesn’t dissolve – Uric acid stones are the only which are known to dissolve completely Criteria for stone to pass: • small size • smooth • solitary .

NSAIDs 5. Dissolution . Antibiotics (UTI. edema of ureteric mucosa) 6. Hydration + Diuretics 2. Medical Therapy 1. Analgesics or narcotics in renal colic 4. Spasmolitics 3.

calcium [calcium stones] 3. Metabolic Screening “once stone removed” . Diet regulation . Prevention of Recurrence 1. Treatment of UTI 4. Correction of obstruction 5.protein [uric acid stones] . ↑ water intake [urine volume] 2.

Interventional Treatment • ESWL – Extracorporeal Shock Wave Lithotripsy Intracorporeal • PCNL – Percutaneous Nephrolithotripsy • URS – Uretero Renoscopy • Laparoscopy • Surgery .

Removal of a stone from the ureter .

Good Luck ! .