Urinary Stone

Disease
Lecture №2
Lecturer : Serhii Dmytryshyn
Urinary Stone Disease - Urolithiasis

 Urolithiasis - is a pathological condition of the urinary tract system which presents with
formation of calculi or stones within kidneys or urinary tract, that have ability to grow and
move.
Frequency of localization of urolithiasis
 Nephroureterolithiasis - 92%
 Cystolithiasis - 7%
 Urethrolithiasis – 1,4%
Epidemiology of urolithiasis

 Incidence - 148.8 per 100 thousands population (Ukraine)

 Vinnytsia region - 254.7 per 100 thousands population (Ukraine)

 Prevalence - 604.8 per 100 thousands population (Ukraine)

 Vinnytsa region - 1028.1 per 100 thousands population (Ukraine)

 In our region, urolithiasis is twice the average in Ukraine. This is due

to the greater mineralization of water.
Diagnostic questions to be answered
before starting treatment
 Side of affection
 Stone localization
 Type of stone
 Size of stone
 Shape of stone
 Surface of stone
 Content of stone
 Clinical manifestation
 Ability to move
 Tendency for reccurency
 Complication
Side of affection

 one-sided
 two-sided
 The only one functioning kidney
Stone localization

 Renal calyx
 Renal pelvis
 Ureter
 Ureteral openings
 Vesica urinaria (bladder)
 Urethra
Type of stones

 Solitary
 Plural
 Coral ( a staghorn renal stone )
 By stone size

 By Stone shape
 wedge-shaped
 rhomboid
 hexagonal

By the surface of the Enveloped (dumbbell) Wedge-shaped

stone
 Flat
 Thorned
Coffin lid Thomboid and rosettes Hexagonal
 Mineral composition

By content of the stone

In the form of crystals:

 Calcium oxalate 85-90%
 Calcium phosphate 3-10%
 Uric acid – 5-10%
 Cystine – 1-3%
 Ammonium phosphate and Magnesium phosphate
(struvite = infectious stone)
(MgNH4PO4) – 5-15%
 By structure
 massive
 porous
 layered

 By density
 super solid (Calcium oxalate, cystine)
 medium solid (non-porous uric acid)
 soft (porous uric acid, struvite)
Tendency to reccurence
for the first time or again

 Complications:
 Hydronephrosis
 Pyelonephritis
 Pyonephrosis
 ARF
 CRF
Forms of clinical manifestation of
nephrouretherolithiasis
 Painless
 With Renal colic
 Moderate pain
 Macrohematuria
 Anuria
Theories of stone formation
 Crystalloid (oversaturation and supersaturation)
 Deficiency of crystallization inhibitors:
 - organic inhibitors: (uromucoids, citrates, peptides)
 - non-organic inhibitors: (pyrophosphates, magnesium, zinc)
 The theory of crystallization inducers (increasing the level of uric
acid increases the Ca oxalate)
 Randal's theory (nucleus-subepithelial calcinosis of vascular
genesis)
 Carr's theory (nucleus-calcinosis lymph genesis )
 Protein-ion theory ( displacement in acidic environment leads to
the formation of urates, displacement in alkaline environment
leads to the formation of phosphate stone. )
 Factors that contribute to stone formation

A. Exogenous:
hot season or climate
food
chemical composition of water
professional factor (hypodynamia) - Exercise moves calcium and phosphorus from blood into bones and muscles

B. Endogenous:
Age: 30-50 years
sex - in men testosterone increases the formation of oxalates in the liver,
in women - the infection contributes to the formation of phosphates
Race: more rare kidney stones in are Negroes, Indians, Jews

Hyperparathyroidism (PTH moves calcium and phosphates from the bones into the bloodstream )

Vitamin A deficiency (Vitamin A keeps the urinary mucosa in good condition )

Anticoagulants, sulfanilamides - in acidic environment lead to the formation of stone.

Gastrointestinal disease - enterocolitis absorbs more calcium and oxalates
Liver dysfunction
Infections (in tonsils, teeth, osteomyelitis)
Factors that lead to stone formation:
Congenital nephropathy:
glomerulopathy,
tubulopathy
Acquired nephropathies :
glomerulopathy,
tubulopathy,
urodynamic disorders,
hemodynamic disorders,
pyelonephritis,
tuberculosis,
chronic damage and urothelial defects,
damage to the renal papilla)
 Calcium oxalate
( Vevelithi monohydrate,
Vedelithi-vevelithi dehydrate )

conditions for formation:

 Hyperoxaluria (excretion of oxalates more than 35 mg / day)

 Hypercalciuria (excretion of Ca more than 300 mg / day)

 Hyperuricemia

 Hypocytrateuria
Urate ( X-ray invisible)

conditions for formation:

 Hyperuricemia

 Hyperuricuria (excretion of uric acid more than 800 mg / day)

 pH of urine <5, 7

 reduction of diuresis < 1.0 L / day

Calcium phosphate ( Hydroxyapatite,
Carbonate apatite – dahlite )

conditions for formation:

 pH of urine 7.2 and higher

 Hypercalciuria

 Hypocytrateuria (excretion of citrate less than 0.6 mmol / day)

 Reduction of magnesium pyrophosphate in urine

 Ammonium phosphate and Magnesium phosphate
(struvite = infectious stone)

conditions for formation:

pH of urine 7.2 and higher
 An infection that splits urea
 oversaturation of urine with Magnesium phosphate

Obligatory urease-producing bacteria (>

facultative urease-producing bacteria
98%)
• Proteus spp.
• Enterobacter gergoviae
• Providencia rettgeri
• Klebsiella spp.
• Morganella morganii
• Providencia stuartii
• Corynebacterium urealyticum
• Serratia marcescens
• Ureaplasma urealyticum
• Staphylococcus spp

0,1–5,0 % strains of Escherichia coli, Entercoccus and

Pseudomonas aereginosa can produce urease
 Cystinuria
 Cystinuria(excretion of cystine more than 100 mg
/ day). Impairment (порушення) in reabsorption
of amino acids: cysteine – water insoluble,
ornithine, lysine, arhinyn
 Causes of hypercalciuria

 Intestinal form - increased absorption in the intestine

 Renal form - reduction of reabsorbtion in the kidneys
 Resorptive form - increased resorption from bone
 Hypercalcemia with hyperparathyroidism, intoxication
with Vitamin D, myeloma.
 Foods high in carbohydrates.
 NORM: Ca / Creatinine
Before saturation < 0,34
After < 0,56

 Absorbtive hypercalciuria
Befote saturation < 0,34
After > 0,56

 Renal hypercalciuria
Before saturation > 0,34
After > 0,56
Causes of hyperoxaluria
 Congenital
- hyperproduction of oxalates or
tubulopathy.

 Acquired - hyperreabsorption of oxalates in

the intestine
Clinical manifestation
Pain in lumbar region Urination of minerals
Hematuria
and calculus.

- Dull ache is a
characteristic feature - increases with
for less mobile
motion and more - Seen in 10-15% of
calculus.
- Sharp pain similar to often in the
the patients.
evening. - Size vary from 0.2
renal colic - seen in 75-95% of
- the patient is to 1.0 cm in
patients. more
constantly moving diameter.
- nausea, vomiting, often presents as
microhematuria.
constipation
 when stone is placed in the middle part of the ureter,
the pain radiates to the genitals. Тhis part of the
ureter was located near the urogenital nerve.
 when the stone is placed in the lower part of the
ureter, dysuric disorders occur. It is due to same
innervation of ureters and bladder.
Diagnostics

 Complete laborory tests

 Ultrasound
 X-ray: observing, excreting, retrograde
 Radionuclide imaging
 MRI, CT Scan
 Chromocystoscopy
laboratory methods
 Urinalysis
 urine pH measure three times during 7 days
 Nechyporenko's urine analysis
 urine analysis for presence of active leukocytes
 urine analysis for sterility, antibioticogram
 Hematological test for blood
 Calcium level in blood and urine
 uric acid level in blood and urine
 presence of cytrate in urine
 presence of oxalates in urine
 magnesium and pyrophosphates levels in urine
 blood phosphates
 blood electrolytes
 blood glucose
 prothrombin index
 Creatinine and urea in blood
 liver function tests
 total protein, blood fractions
Ultrasound
Observing X-ray
Retrograde ureteropyelography
Computer tomografy (CT)
Treatment of nephroureterolithiasis
 I. During the renal colic
 II. Between the attacks:
1. Conservative treatment:
A. Dietary and medical recommendations
B. Physiotherapy
C. Health resorts
2. Invasive treatment:
A. instrumental
B. Ascending litholysis
C. Surgical evaluation of:
- kidney stones
- uretheral stones
- simultaneusly stones of the kidneys and urethers
- pathogenetic: parathyroidectomy, removal of the
obturative factor
Recommendations of the European Association of
Urologists for the treatment of renal colic (2017):

 During renal colic urgently reduce the pain syndrome

 NSAIDs should be preffered as first-line treatment.

 Tramadol or Hydromorphin should be used as second-line treatment.

 Prescribe alpha-blockers to reduce risk of renal colic ( alpha-blockers -

spasmolics for the ureter )
 Renal colic treatment
1. Parenterally:
a) NSAIDs ( Nonsteroidal Anti-Inflammatory Drugs ):
Dexalgin 50 mg 3 time a day IM
Diclofenac 75 mg 2 time a day IM
b) Myotropic spasmolytics
Drotaverin 2 ml (40 mg) IM or IV
Papaverin 2% SC 1-2 ml 2-4 a day or 1 ml IV
Baralgin 5 ml IM or IV
Maxigan (+anticholinergic drug) IV 2ml, IM 2-5 ml 2-3 times a day
c) Cholinolytics (M-blockers)
Atropin 0.1% SC
Platiphylin 0.2% SC 1 ml
Spasmobru IM, SC 2-4 ml 2-3 times a day
d) Narcotic Analgetics
2. Enteral : urolesan
Avisan
Drotaverin and others.

3. Blockade after Lorin-Epstein ( introduction of a solution of novocaine 0.5% 60-80 ml in the

seminal cord)
 Metaphylaxis calcium lithiasis
1. Reducing the amount of oxalic acid in the blood
restriction of products that containing oxalic
acid:
(beans, strawberries, tongue, beet, tea, brain, courgettes,
blueberries, coffee, kidneys, sorrel, grapes, coca cola, liver,
parsley, apples and juice, beer, salted fish, tomatoes, pears,
cocoa, broths , onions, black currants, peppers, nuts, candies,
rhubarb, dried fruits, jam, asparagus, gooseberry, mushrooms,
citruses, mustard, horseradish)

! carbohydrate nutrition leads to increased formation of

oxalic acid;
2. binding of oxalates in the intestine:
 magnesium oxide (Magnesii oxydum aka burned magnesia) for 3
months. - 1.5 years at 0.2-0.3-0.4 g / day 1.5 months, 1 month
break.

 magnesium carbonate (Magnesii subcarbonas) white

magnesium 0.5 g every 6-8 hours.

 magnesium gluconate 150 mg every 8 hours.

3. Reducing the amount of oxalate in the urine:
 pyridoxine (Vit.B6) by 0,02 every 5-6 hours 1-1,5 months
 Do not take extra vitamin C.
 Allopurinol (as hiperurikuria increases the risk of oxalate)
after eating 100 mg every 8 hours long (1 year) courses of 2-3
weeks.
4. reduce the formation of calcium oxalate
in the urine (magnesium instead of calcium binds to oxalate)
 Food enriched in magnesium :
(cereals buckwheat, millet, bread, made from 2-nd grade
flour(low-quality), bran)
 Metaphylaxis urate lithiasis:
1. Diet:
 exclude: kidneys, brain, liver, meat broth, fried and spicy
foods, chocolate, coffee, peanuts.
 limit up to 3 times a week boiled fish, low-fat meat.

1. Diuresis is increased to 2.5 liters.

2. Increased urate solubility.
 Use drugs containing citrate acid that makes urine
alkaline. (pH 6.2-6.8)
When urine pH 5.0 and T = 37,0 C crystallization of uric acid already
occurs when it's content is 60 mg/l.
 With an increase in urine pH up to 6.0, crystallization of uric acid
does not occur even when it's content is 660 mg / l.

 Composition of Blemaren:
Citric acid - 39.9 parts
Potassium bicarbonate - 32,015 parts
Sodium Citrate - 27,085 parts
3. To decrease the formation of uric acid -
xanthine oxidase inhibitor are used:
 allopurinol 100 mg every 8 hours after meals, with
duration of courses for 2-3 weeks to a year.

 benzomarone 0.05-0.1 g / day.

 Allomaron 2-3 times / day.

 Phosphate lithiasis: Diuresis is reduced to 1.5
liters
1. Diet:
 limiting dairy and plant foods, potatoes, meats, pickles,
milk products, muffins, juice, fruit juice, vegetables
 recommend fatty foods (salo), eggs, cereals, flour
products, sometimes meat, birds, fish, apples, honey,
sugar, tea, coffee, bush broth, cranberries, sea
buckthorn, mushrooms, peas

2. Antibiotic therapy (after determining the sensitivity

3.Acidification of urine:
 hydrochloric acid, diluted by 10-15 drops to
half cup of water, every 6-8 hours after
meals.
 Methionine 0.5 g half-an-hour before meals
every 6-8 hours, course 10 days.
 Amonium chloridi 0,5 g every 4-5 hours
during 3-4 days, after the same brake -
repeat the course.
4. Reduction of phosphates adsorption in the intestines:
 Almagel (not containing Mg) for 2 teaspoons every 6 hours
30 minutes before meals.

NB! Do not prescribe medications that contain Mg!

5. Blocking of the bacterial urease
(necessarily in patients with nephrostomy, with remaining
stones)
 Acetohydroxamic acid 0.25 g every 8-12 hours per
month.
 Cystine lithiasis
1. Reducing the concentration of cystine
increase diuresis to 3-4 liters per day
2. Limiting salt intake in food and protein
3. Improvement of cystine solubility via alkalization of urine

 citrate mixtures
4. For binding of cystine and formation of more soluble cysteine
 D-penicillamine (trade names: bianodine, kuprenil) in the table, 0,5 g at Caps. every 6-8
hours
 Alpha-mercaptopropionilglycine 10 mg / kg / day (side effects in 30-50% of patients - use
carefully).
 Percutaneous or ureteroscopic ultrasound lithotripsy - the method of choice in the
treatment of cystine lithiasis, since the RSWL is ineffective, and the open operation is not
reasonable due to the high frequency of relapses.
 Water-resort treatment
Calcium urolithiasis
low-mineralized water:
- Yesentuki N. 20
- Naftusia
- Sairme
- Zbruchans'ka

Urate urolithiasis
Alkaline water:
- Yesentuki N. 4,17
- Smirnovs'ka
- Slovians'ka
- Borzomi
- Morshynska
- Zbruchans'ka

Phosphate urolithiasis
Water that acidifies the urine
- Dolomitnyi narzan
- Naftusia
instrumental treatment of Nephroureterolithiasis
1. Extracorporeal shockwave lithotripsy ( ESWL )
2. Transurethral catheterization of ureter and kidney stenting
(transurethral)
3. Percutaneous puncture nephrostomy (PCNS)
4. Removal of a stone by loop (ureterolithoextraction)
5. Dissection of the urethral opening and endoureterotomy
(transurethral)
6. Transurethral pyelolithotripsy and ureterolithotripsy
7. Percutaneous nephrolithotripsy (PCNL)
8. Vibrotherapy
9. Physiotherapy
Indications to catheterization of the ureter or
percutaneous nephrostomy (PCNS) during the renal
colic:
 A stone in only one remained kidney or ureter of
one kidney
 Acute pyelonephritis
 A stone of large size (6 mm and >) in the upper
half of the ureter.
 Motionless stone
 High intensity pain with nausea, vomiting.
Stenting a patient with acute subrenal ARF
Stentation of a patient with complete doubling
of both kidneys
A set for percutaneous nephrostomy
(PCNS)
Percutaneous (puncture) nephrostomy
(PCNS)
Treatment of kidney stones
Stone <2.5cm Complication Stone >2.5cm

ESWL Absent Percureus puncture lithotomy or

open surgery

ESWL Hydronephrosis Percureus puncture lithotomy or

open surgery

Open surgery: segment resection Narrowing of pelvico-ureter Open surgery: segment resection
+lithoextraction+ureterouretero segment +lithoextraction+ureterouretero
anastomos or laparoscopic anastomos or laparoscopic
surgery surgery

PCNS, then ESWL Acute pyelonephritis Emergent open surgery

( pyelolithotomy )

Nephrectomy Pyonephrosis Nephrectomy

Extracorporal Shockwave
Lithotripsy(ESWL): Calculi breaks
down under the action of shock waves,
which are generated outside the patient's
body and specially focuse on the calculi.
Three basic principles of shock waves generation
o 1. Electrohydraulic - inter-electrode discharge leads to evaporation of certain
volume of water and local increase in pressure.
o 2. Electromagnetic - through the coil alternating current get passed, causing
the appearance of an alternating magnetic field around it. Under the action of
this field, the membrane begins to vibrate and generate a shock wave, which
lens focuses on the stone.
o 3. Piezoelectric - part of the sphere is covered with a large number of
piezoceramic crystals (4-5 thousand). To all crystals at the same time an
alternating current of high voltage is brought, which causes a synchronous
change in their shape. The fluctuations of pressure occurring near each crystal
are summed up in the focus of the sphere around the stone. Generated outside
the body, short impulses of energy in the form of shock waves focus on
concrements.
The pressure in the focal zone reaches 160 MPa (1600 bar), which leads to the
destruction of concrement.
Atmospheric pressure on the Earth surface is around 0.1 MPa
Extracorporeal shockwave lithotripsy

 Manipulation is performed under intramuscular or intravenous

anesthesia and does not require special training;
 stationary observation is carried out within 1-2 days.
 The session lasts about 1 hour,
 it is possible to repeated ESWL sessions.
 In 92-96% of cases after the ESWL session, the first three acts
of urination should have moderate pink urine!
Bun intensive hematuria indicates the possibility of forming a
hematoma of the kidney !!!
Indications for ESWL are:
 Kidney stones < 2.5 cm
 Stones of the ureters < 2.5 cm
Contraindications for ESWL are:
 The impossibility of accurately directing a stone into a zone of shock wave
(deformation of the spine column, musculoskeletal system, obesity, etc.).
 -diseases that leads to a coagulation system impairment;
 cardiovascular disease (including implanted cardiac pacemakers);
 long-term administration of anticoagulant drugs;
 hypertonic disease in severe forms
 aneurysm of the abdominal aorta, renal arteries;
 severe forms of diabetes mellitus;
 - peptic ulcer of the stomach and duodenum in the stage of exacerbation;
 - acute pyelonephritis; chronic pyelonephritis in active inflammatory stage;
 - pregnancy
 - acute cholecystitis, cholangitis, pancreatitis;
 - menstruation;
 - decreased kidney function more than 50%, severe forms of renal failure;
 - kidney tumor and cavernous kidney tuberculosis;
 -presence of obstruction (narrowing) below the location of stones.
Extracorporeal shockwave lithotripsy (ESWL)
of the kidney stones right child 8 months
Non-inflammatory complications of Extracorporeal lithotripsy :
 Hematuria in 90% of cases.
 The skin petechiae up to 30% of cases
 "Stone path“
 Subcapsular and paranephral hematomas.
 "Stone path“
• - it is a cluster of small or large fragments of the stone in the upper
urinary tract that does not go away for a long time and complicate the
outflow of urine.
Reasons:
 Destruction of a large calculus in one session
 A large number of fragments that went into the ureter at the same time
 Anatomical and functional state of the pelvicocalyceal system.
Treatment:
Conservative: - antibacterial and antispasmodic therapy
-repeated ESWL session
Surgical: - Stent installation
-Ureterolithotomy
 Contact lithotripsy
The energy sorved by a special endoscope without surgical
intervention.
Ultrasound lithotripsy, when a source of ultrasound
oscillations contacts with the stone,
Pneumatic lithotripsy. The force carried out on the stone
by a mechanism is similar to a punching hammer. Precisely
targeted impulses are capable of quick breakdown of the
stone.
Laser lithotripsy. Energy lead to the stone from an
external laser by a thin luminodiod . Laser impulses
generate shock waves , which, in the background of local
temperature rise, lead to the destruction of the stone
Laser is flexible. Used in rigid, flexible
ureteroscopes, nephroscopes, cystoscopes. The
disadvantage of ultrasound-based and
pneumohydraulic-based are their rigidity.
Contact lithotripsy differs by:
Small traumatism;
high efficiency;
the possibility to get rid of a
few concrements
simultaneously.
Percutaneous nephrolithotripsy (PCNL) and
ureterolithotripsy
Indications:
 cases of inefficiency of extracorporeal lithotripsy (ESWL)
 the impossibility of conducting an open operative intervention
 obstructive stones of the kidneys and ureters,
 the presence of stricture of the ureter, which can be eliminated by this
method
 in combination with extracorporeal lithotripsy in patients with large or coral
kidney stones.
Contraindications percutaneous nephrolithotripsy :
 a large distance of the kidney from the skin (in obesity, etc.).
 blood coagulation impairment
 pathological kidney mobility
Percutaneous nephrolithotripsy
Percutaneous nephrolithotripsy
Percutaneous nephrolithotripsy
Percutaneous nephrolithotripsy
Percutaneous nephrolithotripsy
Complication:
 bleeding
 perforation of the wall of the renal pelvis or ureter
 the formation of urogematoma

 ADVANTAGES VERSUS OPEN SURGERY:

 reduction of complications
 the absence of postoperative hernias
 stationary treatment for only 4-5 days
OPEN OPERATIVE INTERFERENCE
Indications:
Large coral(strvite) stones
Secondary calculus, if necessary in reconstructive urinary
tract surgery
 calculus of the kidneys, complicated by purulent-
destructive pyelonephritis
calculus of the kidneys, complicated by renal insufficiency
Kidneys and ureters stones with contraindications to
extracorporeal lithotripsy and endoscopy
Posterior pyelolithotomy performed in
90% of cases
Frontal (anterior)
pyelolitotomy
Lower pyelolithotomy (up to 3%). If there are main
vessels on the front and back surfaces of the renal
pelvis, the difficulty of approaching the renal pelvis
and the presence of scarring
Subcortical pyelolithotomy is used to remove large
stones located in a renal pelvic of the intra-renal type.
In this way, the surface of the renal pelvic increases to
perform a sufficient access during surgery, without
injuring the pelvic-ureter segment.
Nephrolithotomy can be applied to various kidney
stones, when removal through the renal pelvic can
be traumatic. Conduct a parenchyma dissection
over a calyx in which there is a stone, then dissect a
cavity and remove a stone.
Anatrophic Nephrolithotomy Indications:
 complex stereometric configuration of coral stone
 incomplicated access to the renal pelvis - loss of renal function by 50%
 - the presence of thinned parenchyma.
 The incision is made along the rib of the kidney from the upper to the lower
segment with the disclosure of the entire CPS(calyx-pelvis system).
 The operation is quite traumatic
Drainage of CPS(calyx-pelvis system)
Establishment of terminal or ring nephrostomy
Postoperative PERIOD

 Drug therapy, aimed at restoring the function of the kidney (improvement of

microcirculation, infusion therapy) Prevention of inflammatory complications
(antibacterial, anti-inflammatory therapy) Adequate functioning of
nephrostomy or pyelostomy drainage (removed for 14-20 days, after
performing the control excretory urography)!
Nephrectomy
Nephrectomy
Ureterolithotomy
 Rarely used, is approved if the is ineffectiveness or inability
to perform extracorporeal lithotripsy and endoscopic
surgery.
 Often in cases with large stones of the upper third of the
ureter, which are complicated by acute purulent
pyelonephritis (additionaly combined by revision of the
kidney, decapsulation and nephrostomy)
 After the resection of the ureter and the detection of a
stone in it, there is perfomed longitudinal section of the
wall of the ureter above the standing stone. After removing
it and checking the passage of the ureter, the incision is
sewn.
Cystolithiasis
Cystolithiasis Diagnosis
Cystolithiasis. Cystolithostomy
Thanks for your attention!
 Treatment of combined stones of kidneys and
ureters Nefroureterolithiasis

one-sided two-sided

Priority Side Priority, where

Kidney-
Kidney and - stone of the ureter
-expressed pain
- a concrement, which kidney
upper 1/3 is located below -one stone
-a better kidney
function
Kidney and Kidney- -later obstructed
middle 1/3 ureter in the case of anuria

Kidney and
lower 1/3
Ureter-
Upper, ureter
middle and
lower 1/3
Re-stenting of the pregnant women
 The patient at the time of examination was complainig
about the presence of a stent, which was established
during pregnancy regard to the stone of the ureter, after
the labour was diagnosed stent calcification and stone
formation on the renal and bladder's ends of the stent.
 Unable to delete it. Two urethroscopic lithotripsyfor the
stone in ureter have been performed and the bladder's
part of the stent removed with the calculus. Second
stent was installed parallel.
 After this, ESWL (extracorporal shockwave lithotripsy) on
the renal end of the stent was performed.
 There was done five sessions of lithotripsy of kidney's
end of the stent, moreover three last sessions were
performed at maximum power.
Causes of uric acid lithiasis
1. Impairment of synthesis of purines . Excessive activation of xanthine
oxidase leads to the conversion of hypoxanthine to xanthine , and the latter
into uric acid ,which is accumulated in the blood (hyperuricemia), as a result
of the absence of the liver enzyme urate oxidase (UO), or uricase, which
converts insoluble in water uric acid into allantoin.
2. Idiopathic uric acid urolithiasis. Constantly low urine pH, but the content
of uric acid in the blood and urine is normal.
3. Urinary urolithiasis as a result of hyperuricemia. in some diseases
(gout, chemotherapy, myeloproliferative disorder, lymphoma, Lesch–Nyhan
syndrome).
4. Urinary urolithiasis as a result of chronic dehydration
(chronic diarrhea, inflammatory intestines disease, ileostoma, increased
sweating affect in the concentration and pH of the urine)
5. uric acid lithiasis, caused by hyperuricuria without hyperuricemia, products
rich in purines (red meat, sardines); uricosuric drugs (salicylates, thiazides)
Indications for invasive treatment of ureterolithiasis (ESWL,
ureterolithoextraction or lithotripsy, open surgery):
 complete obstruction of a single kidney
 moderate uncollected colic
 a stone that does not move
 an infection that is not sensitive to ABT
Stages of stone formation

a. Nucleation - the process of minimal crystalline particle formation

b. Epitaxis – the growth of a crystal
c. Aggregation - the layering of other crystals
Stones fron Calcium Oxalate

 In healthy person normally up to 5x108 CFU/ml of Oxalobacter formigenes

 this count of O.formigenes and utilize 0,501,0 g og oxalate per day

CFU=colony-forming unit
 Unic acid is freely filtrated in glomeruli. 99% of uric acid then get reabsorbed
in proximal tubules. After 50% get secreted and 40% undergo postsecretional
reabsorbtion. The end-up excretion of uric acis rmain only 10%.
What do we do to decrease the number
of kidney traumatization?
 Careful selection of patients and patient examination (diabetes mellitus, signs
of inflammatory process, signs of hydronephrotic transformation)
 BP examination before the procedure.
 Gradual power incresing during lithotripsy
 With caution use high-power impulses in patient with stones in kidneys,
pelvic-ureter segment and in upper 1/3 of ureter up to the lower pole level.
 Without urgent indications we delay lithotripsy in patiens with menses and try
to wait few days after this period passes.
 Limit thermal procedures for 3-5 days after session of lithotripsy.

 All written above let us avoid exceeding international mean data in frequency
of kidneys and retroperitoneal space traumatization.
 Apatite - group of phosphate minerals with general chemical formula
Ca10(PO4)6(OH,F,Cl)2.