Wendi Rachman

Urolithiasis

Urolithiasis (from Greek oûron-urine and lithos-stone) is
the condition where urinary stones are formed or located
anywhere in the urinary system.
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

Urolithiasis occurs in all parts of the world

A lifetime risk:

2-5% for Asia

8-15% for the West

Hot Climate

Dietary habits

Hereditary factors

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

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
The presentation is variable.


Patients with urinary calculi may report

Pain

Infection

Hematuria

Asymptomatic

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

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 calculi are often
relatively asymptomatic.

Branched kidney stone occupying
the renal pelvis and at least one
calyceal system.

Manifest as infection and
hematuria.

Asymptomatic bilateral
obstruction

Solitary Kidney with
obstructive stone

Depends on the level of
obstruction and its degree:

ureteropelvic junction

pelvic brim

ureterovesical junction

Stones obstructing the
ureteropelvic junction may
present with mild-to-severe
deep flank pain without
radiation to the groin

Cause pain that radiates anteriorly and caudally.

Can easily mimic appendicitis on the right or acute
diverticulitis on the left.

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

Usually asymptomatic and are passed relatively easily
during urination.

Rarely, a patient reports positional urinary retention
(obstruction precipitated by standing, relieved by
recumbency).
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

The diagnosis of nephrolithiasis is often made on the
basis of clinical symptoms alone, although confirmatory
tests are usually performed.
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

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

IV access to allow :

Fluid

Analgesics:

Paracetamol

NSAID

Opiod

Antiemetic

In case of infection:

Urine culture

Blood culture accordingly e.g. febrile

Antibiotics

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

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

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

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

Relative indications to consider for a possible admission
include comorbid conditions

diabetes

dehydration

renal failure

immunocompromised state

perinephric urine extravasation

pregnancy

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.

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.

General recommendation not to wait longer than 4
weeks for a stone to pass spontaneously before
considering intervention.

About 15-20% of patients require invasive intervention
eventually as emergency or electively due to:

stone size

continued obstruction

Infection

intractable pain

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

Obstruction relief:

Ureteral stent insertion

Percutaneous nephrostomy

Definitive surgical treatment:

ESWL

Ureteroscopy

PCNL

Open, laparoscopic and robotic
pyelo-lithotomy, ureterolithotomy,
cystolithotomy

Open anatrophic nephrolithotomy

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

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

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

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.

Indicated if stent placement is
inadvisable or impossible.

In particular patients with
pyonephrosis who have a UTI or
urosepsis exacerbated by an
obstructing calculus

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

The patient, under varying degrees of anesthesia

The shock head delivers shockwaves developed from an

Electrohydraulic

Electromagnetic

piezoelectric source

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

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 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

In some cases, a combination
of SWL and a percutaneous
technique is necessary to
completely remove all stone
material from a kidney.

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

increased requirements for blood
transfusion.

Metabolic evaluation is done by a typical 24-hour urine
determination of:

urinary volume

pH

specific gravity

Calcium

Citrate

Magnesium

Oxalate

Phosphate

uric acid.

Most common findings are

Hypercalciuria

Hyperuricosuria

Hyperoxaluria

Hypocitraturia

low urinary volume

Chemoprophylaxis of uric acid and cystine calculi
consists primarily of long-term alkalinization of urine.

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

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.

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.