URINARY TRACT STONE
DISEASE
UROLITHIASIS
ETIOLOGY/PREDISPOSING FACTORS
MULTIFACTORIAL
GENDER: MALE >FEMALE (2-3 TIMES)
RACE/ETHNICITY: MORE COMMON IN WHITE POPULATION (4-5 TIMES)
GEOGRAPHY/CLIMATE: Common in hot or dry climate
OBESITY: higher the BMI, more chance of stone formation
(>30kg/m2 is a risk factor)
URINARY TRACT DISEASE: any disease causing stasis eg:
hydronephrosis, bladder outlet obstruction, UTI
PREVIOUS STONES: risk of recurrence is 35-75% at 10 years
SYSTEMIC DISEASES: Diabetes, vitamin A deficiency,
hyperparathyroidism
METABOLIC CAUSE: hypercalcemia, hypercalcuria, hyperoxaluria,
hyperuricosuria, cystinuria, hypocitraturia
HYPERCALCIURIA
Absorptive - increased calcium absorption from GIT, increased
calcium load to kidney, increased precipitation of calcium ions
Renal - Renal tubular acidosis (bartter syndrome ), increased calcium
excretion in kidney, precipitation of calcium ions
HYPERCALCEMIA: increased calcium in blood, increased calcium load
in kidney, precipitation of calcium ions (hyperparathyroidism, milk
alkali syndrome, prolonged immobilzation)
HYPEROXALURIC CALCIUM STONES
Increased oxalate in renal tubules
Enteric - bowel resection - increased fat malabsorption - fat combines with
calcium to form soap formation in gut - increased in free oxalate levels in
gut - increased absorption - increased filtration by kidney - increased
oxalate load - precipitation of calcium ions
Primary hyperoxaluria (genetic disorder - autosomal recessive) (defective in
metabolism of oxalate)
TYPE 1 - alanine deoxylate amiontransferase deficiency
TYPE 2 - D-glycerate dehydrogenase deficiency
Dietary - increase in oxalate rich food (spinach) - increase oxalate
reabsorption - increased load to kidney - precipitation of ca stones - calcium
oxalate stones
HYPOCITRATURIA
Citrate and magnesium is a natural inhibitor of stone formation
Renal tubular acidosis
Chronic diarrhoea (hyperacidic state)
Thiazide drug induced
PATHOGENESIS
Supersaturation of urine
Precipitation (nucleation), crystal growth and aggregation
Lack of inhibitors of stone formation (citrate, magnesium,
pyrophosphate)

COMPOSTION OF STONES
Stones are composed of
Crystals
Matrix
Types of stones
CLASSIFICATION OF STONES
According to composition
According to X - ray characteristics
According to etiology
Accordting to stone location
According to composition
A) Calcium stones
Calcium oxalate
Calcium phosphate
Calcium carbonate
B) NON CALCIUM STONES
Uric acid stone
Magnesium ammonium phosphate (STRUVITE STONE)
Cystine
Xanthine
Drug stones (silicate, Indinavir, triamterene
CALCIUM OXALATE
Irregular in shape and covered with sharp projections
Symptomatic - hematuria
Most common type
Calcium oxalate monohydrate stone - radioopaque
STRUVITE STONE
Magnesium, ammonium and phosphate
Smooth and dirty white in colour
Infection stones ( urea- spillting organisms : proteus, pseudomonas,
providencia, klebsiella, staphylococcus and mycoplasma)
Asymptomatic - silent for years
Staghorn calculus
Poorly opaque
URIC ACID STONE
Gout
Myeloproliferative disease
Malignant condition
pH < 5.5
Hard, smooth and often multiple
Yellow to reddish brown and have multifaceted appearance
Radiolucent
ACCORDING TO X RAY CHARACTERISTICS
RADIO - OPAQUE : calcium oxalate dehydrate, calcium oxalate mono-
hydrate, calcium phosphates
POOR - RADIO - OPAQUE: magnesium ammonium phosphate, cystine
RADIOLUCENT: uric acid, xanthine, 2,8 - dihydroxyadenine, drug
stones (silicate, indinavir, triamterene)
ACCORDING TO ETIOLOGY
NON-INFECTION STONES: Calcium oxalate, calcium phosphate, uric
acid
INFECTION STONES: magnesium ammonium phosphate, carbonate
apatite, ammonium urate
GENETIC CAUSES: cystine, xanthine, 2,8 - dihydroxyadenine
DRUG STONES
ACCORDING TO STONE LOCATION
KIDNEY: upper, middle, lower calyx or renal pelvis
URETER: upper, middle or distal ureter
URINARY BLADDER, URETHRA
CLINICAL FEATURES
Pain
Hematuria
Fever
Nausea and vomitting
PAIN
Felt in renal angle or costovertebral angle
Constant dull ache (renal calculi) to a very severe colicky pain
(ureteric calculi)
Radiate across the flank anteriorly toward the upper abdomen and
umbilicus and may be referred to the testis or labium (T10 - T12)
HEMATURIA
Intermittent, painful, gross hematuria
Microscopic hematuria (10-15%)
FEVER
Obstruction leads to stasis, leads to infection
Acute pyelonephritis : acute loin pain, fever with chills and rigour
and septicaemia
Acute pyelonephritis in the presence of urinary obstruction is a
urological emergency
SIGNS
Tenderness in the renal angle
INVESTIGATIONS
URINE ROUTINE AND CULTURE SENSITIVITY
RENAL FUNCTION TEST
PLAIN X RAY KUB
USG KUB
IVU
CT KUB
URINE ROUTINE AND CULTURE
PUS CELLS : infection
RBC: hematuria
URINARY pH: struvite stones are formed in alkaline, calcium oxalate ,
cystine and uric acid stone are formed at acidic stones
CRYSTALS: cystine - hexagonal, struvite - coffin lid, calcium apatite
and uric acid - amorphous powder, calcium oxalate dehydrate stone
- bipyramids, calcium oxalate monohydrate stones - dumbbell
shaped
CULTURE AND SENSITIVITY
RENAL FUNCTION TEST
Serum creatinine
Blood urea nitrogen
Measurement of GFR
Serum electrolytes
PLAIN X RAY KUB
90 % of renal stones : radio - opaque
Renal stone
A round radi-opaque
shadow at the level
of L3 vertebra on
right renal area
Bilateral staghorn calculi
Bilateral multiple
branching
radiopaque
shadow along the
L1-L4 level
Upper ureteric stone
An elongated radio-opaque
shadow at the level of L4
vertebra on left side
USG KUB
Stone: bright echogenic structure casting posterior acoustic shadow
Comment on
stone,
hydronephrosis,
hydroureteronep
hrosis, cortical
thickness and
opposite kidney,
bladder and
prostate
Hyperechoic structure casting posterior acoustic shadow urinary bladder
Hydronephrosis
IVU
Presence of stone
Size and location
Degree of renal
obstruction
Condition of
opposite kidney
Static function of
kidney
CT KUB
NON-CONTRAST CT SCAN: imaging of choice/gold standard in
patients presenting with acute renal colic
Location, size and density of stone (HU)
Diagnose radiolucent stone
CONTRAST ENHANCED CT SCAN:
Hyperdense structure at pelvis od both kidney
STONE ANALYSIS
X - ray diffraction
Infrared spectroscopy
Metabolic analysis: A) 24 hour urine analysis for calcium, uric acid,
phosphate, citrate and oxalate B) blood test: serum calcium, uric
acid and phosphate), parathyroid hormone
MANAGEMENT
Conservative management
Emergency management
Surgical management
Prevention of recurrence
CONSERVATIVE MANAGEMENT
Observation: calculi less than 4mm usually pass spontaneously and
should be observed
50% of calculi between 4mm and 6mm pass spontaneously
Adequate hydration
ANALGESIA: NSAID
MANAGEMENT OF URETERIC CALCULI
CONSERVATIVE
Small stones < 5mm
Adequate hydrations
Analgesics
INDICATION FOR EARLY INTERVENTION (fever, increased RFT) - PCN
with DJ STENTING
DEFINITIVE MANAGMENT
URSL OR URS + BASKETING (dormia basket)
Failed conservative management
Fever
Deranged RFT
Large stones
RENAL CALCULI
ESWL - extracorporeal shockwave lithotripsy (up to 1.5cm)
Electromagnetic shockwaves
Fragmentation of stones occurs
Spontaneously pass through
DISADVANTAGES: 1. Fragmentation may not be complete, 2. Failure
to fragment, 3. Multiple settings, 4. STEINSTRASSE (URSL + DJS)
RIRS - retrograde intrarenal surgery
Flexible ureterorenoscope (distal 10 cm is flexible)
Indication : stones <2cm
Complication: infection
PCNL
Percutaneous nephrolithotomy
Indication: large stones > 2cm, obstructed infection, lower calcyceal
stones, hard stones, ureteric strictures
Complications: 1. Bleeding, 2. Solid organ injury (liver, spleen), 3.
Colonic perforation, 4. Pneumothorax, 5. Hydrothoxac
EMERGENCY MANAGEMENT
INDICATION: sepsis and/or anuria in obstructed kidney
URGENT DECOMPRESSION : to prevent complications in infected
hydronephrosis secondary to stone-induced
Decompression by placement of an indwelling ureteral stent (DJ
STENT)
percutaneous placement of a nephrostomy tube
Antibiotics and analgesics
SURGICAL MANAGEMENT
INDICATIONS FOR SURGERY
Large symptomatic stones
Infection above the site of obstruction
Failure of conservative treatment
Evidence of renal impairment eg: rising creatinine
Presence of anatomical abnormalities which predispose to stone
formation (PUJ obstruction)
GUIDELINES
PCNL: stone size more than 2 cm, hard stones (>1000HU) or where
other minimal invasive technique is failed
RIRS: stones size 1-2cms, Lower calyces stones
ESWL: size up to 2cm but less than 1cm for Lower calyx
SPECIFIC GUIDELINES
1. Oral potassium citrate to alkalinize the urine
2. Allopurinol or febuxostat is used to treat uric acid stones
3. Thiola or penicillamine for cystine stone
4. Thiazide diuretics for hypercalciuria
5. Acetohydroxamic acid for struvite stone
OPEN SURGERIES
PYELOLITHOTOMY
ANATROPHIC LITHOTOMY
THANK YOU
THANK YOU
