Upper Urinary Tract Calculi

Dr Ahmed Rehman

FCPS (URO)

Assistant Professes of urology

Learning Objectives

• To enumerates factors involved in stone formation and describe their role

• To describe clinical features of urolithiasis

• To name investigations to workup a case of calculus

• To describe different stages of disease

• To choose suitable treatment option for each stage of disease

Urolithiasis

• Urinary stones are pieces of solid matter formed in the urinary tract out of normal or

abnormal urinary constituents.

• Calculi are polycrystalline aggregates composed of varying amounts of crystalloids and organic matrix.

Urolithiasis

• Commonest urological problem in Pakistan • 3rd most common problem in West after

infections and prostate• Ancient time \ under developed world common

stone was bladder• Now the trend has shifted to kidneys, thanks to

urbanization and civilization • Roughly 3 to 1O% people suffer with a roughly

5O % recurrence in 5 years • Merits higher in Pakistan, than in the West, as a

cause of ESRD

Upper Urinary Tract Calculi Etiology

– Complex and not exactly known– Only1O to 15 % cases cause can be found– Rest labeled idiopathic – Is not a single disease entity, end result of

many known \ unknown factors– Has been called a MULTI SYSTEMIC disease

rather than a mere urinary problem • Diseases of other systems set environment ripe for

pathological uncontrolled biomineralization( stone formation, which in that case is a manifestation or complication of that disease.

– A disease or a symptom of diseases a big Q

Stones Types

• Calcarious calculi 8O%– Calcium oxalate

• Non calcarious calculi– Uric acid 5 to !O%– Cystine <2%– Xanthine– Phosphate ammonium magnesium phosphate 5 to

1O%• Mix calculi • Matrix calculi• Indinavir, silicate, triamterene

Etiological factors • Heredity • Age & sex effect• Dietary factors• Climatic & seasonal factors• Geography • Water intake• Occupation• Social class• Obstruction \ stasis congenital and acquired• Infections• Altered urinary solutes and colloids

– Dehydration– Increase conc of promoters or decrease conc of inhibitors– Metabolic disorders– Hyperparathyroidism– Prolonged immobilization

• Heredity – Renal tubular acidosis,– cystinuria– xanthinuria

• Age – Peak age 2O to 4O– Extreme ages association with obstruction

• Sex– More common in males 3 to 1

• Climatic & seasonal factors– Dry hot plains\deserts and cold high altitudes = perspiration,

water intake – Sunlight exposure vitamin D activation

• Geography – Well defined stone belts environmental factors

• Water intake– Low intake as opposite to perspiration, losses, requirement – Mineral content zinc \ very hard and very soft water

• Occupation– Sedentary , managerial professionals

• Affluent Social class animal protein

p

Dietary factors • High protein diet • High Salt content • Low water intake• High calcium, oxalate and phosphate diet• Low dietary citrate• Vitamin A deficiency bladder calculi• Fluid intake

Steps of stone formation

• Precipitation \ crystallization• Saturation, Super saturation renal papilla

• Nucleation– Homogeneous & heterogeneous – Free & Fixed particle nucleation

• Crystal retention, Crystal growth and aggregation concretions, microliths

• Role of matrix nidus, glue, inhibitor, bystander

• Inhibitors & promoters of crystallization. metastable

Theories of stone formation

• Crystallization Precipitation theory • Nucleation theory• Crystal inhibition theory• Fix particle theory

– Randalls plaque renal papilla– Carr microliths lymphatics

• Theory of mass precipitation \ intranephronic precipitation

• Matrix nucleation theory

Calcium calculi etiology

• Hypercalciuria– Absorptive – Resorptive Hyperparathyroidism– Renal induced– Idiopathic

• Hyperuricosuria• Hyperoxaluria

– Chronic diarrhea– Enteric – Primary

• Hypocitraturia

p

• Hypercalcemic nehrolithiasis– Primary hyperthyroidism– Malignancy associated hypercalcemia– Granulomatosis \ sarcoidosis– Hyperthyroidism– Glucocorticoid induced hypercalcemia– Pheochromocytoma– Immobilization

• Hypomagnesuria

• Renal tubular acidosis and calcium phosphate stones

• Gout and uric acid stones

• Inborn errors of metabolism

Ureteri calculi Origion

• Nearly always take birth in kidney

• Exceptions– Stones in ureterocele– Stones in kinked / dilated ureters– Stones in strictured / stenosed ureters– Stones in ureteric diverticulae– Stones in schistosomiasis affected ureters– Encrustations on foreign bodies

» Stents» sutures

Clinical Features• No symptoms • Pain

– Renal pain renal angle > upper abdomen,– Ureteric colic

» Acute, agonizing pain» Rolls around as excruciating sharp pain supperimposed uppon a background of continous discomfort (peristalsis

pushing stone down).• Upper ureter = similar to renal colic• Lower down = loin to groin, genitalia, anterior aspect of thigh, retracted tender testis• Intramuural = ref to tip of penis,

strangury (strong urge associated with failure to void except a few drops of blood stained urine)

– Dull (renal) ache due to hydronephrosis– Consistant dull pain of impected stone, relieved by rest

• Pyuria, • Haematuria Microscopic\ gross• Fever, abscesses Infection• Nausea & vomiting• Acute renal failure \ anuria• chronic renal failure• Silent loss of kidney• Squamous cell carcinoma of renal pelvis • Perforations with fistula formation external, enteric

Clinical Examination

• No significant sign

• Some tenderness and rigidity over renal angle or some part of course of ureter

• Distress,

• Tachycardia, Fever, hypotension sweating

• Palpable kidney

Differential diagnosis• Skin / subcutaneous tissues ---- Herpes• Muscles – spasm, psoss abscess• Bones – caries spine, psuedo renal (Radicular ) pain• Lungs - Puemonia, plurecy,effusion• Liver – hepatitis, abscess, • GB – cholecystitis• Appendicitis, typhlitis, large bowl obsruction• Salpingitis, ectopic pregnency• Ovarion cyst / tortion• PID• Splenomegaly• Hydrnephrosis / renal mass, pyelonephritis• Adrenals diseass• Mural / extramural ureteric obstruction• APD / Inferior wall MI• Testicular pain, varicocele• malingering

Complications

• Pyonephrosis• Anuria • Abscess• Erosion and extravasation of urine• Urinary fistulae formaation• Loss of kidney / CRF• Septicemia• Cancer

Sites of impaction of ureteric calculi

• PUJ

• Iliac artery crossing

• Juxtaposition to vas or broad ligament

• Entrance into bladder

• Ureteric orifice

Investigations

• Baseline RFTs• USG – hydro ureteronephrosis / stone• X-ray KUB ROS

false negative – small stone,obscured by gases, bones

• IVU/ delayed films• Spiral CT• Retrograde urography• Renal scan

Emergency Treatment

• Pain relief

• Control of Infection

• Control of vomiting

• Hydration status

Treatment of renal calculi

• No treatment <4mm• Conservative treatment < 5 to 8mm• Noninvasive treatment ESWL \ stenting• Conventional treatment

» Pyelolithotomy, » Extended pyelolithotomy» Nephrolithotomy» Nephrectomy

• Minimal invasive treatment – PCNL– Sandwich therapy PCNL >ESWL >PCNL– RIRS \ URS– Laparoscopic pyelolithotomy

Treatment of ureteric calculi

• Expectant \ conservative

• Definitive therapy – Noninvasive – Minimally invasive– Invasive

Expectant treatment

• Relief of pain– Roll of NSAIDS– Roll of sposmolytics– Roll of IV fluids– Roll of diuretic– Roll of steroids– Roll of edema reducing agens– Roll of rest / exercise– Roll of urinary alkalization– Roll of antibiotics– Roll of chemotherapy– Roll of homeo therapy / indegenous medicine

• assessment of renal function & back pressure• Follow up -- 4-6 weeks

Indications to abandon conservative therapy

– No progress– Intractable pain– Stone enlarging / too large a stone– Fever (UTI)– Oligurea / anurea / Renal function deterioration

• complete obstruction– Bilateral– Unilateral – solitary kidney

– Profession

Spontaneous passage

• Size– 1-2mm ---- pass eventually – 4-5 mm --- 40-50%– >6mm ---- <5%

• Site

• shape

• Degree of hydronephrosis / impection

• Obstructive lesion

Definitive treatment Noninvasive

• ESWL in situ (with out push back)– Upper ureter – suppine– Lower and mid --- prone

– Countraindication : impected stone– Infected system ( stenting or PCN followed by definative

treatment )– Distal obstruction

Definitive treatmentminimally invasive

• Endoscopic removal– Dormia basket ============NOT USED NOW– Ureteric metotomy- transurethral ureterolithotomy– Uretro renoscopy

• Mechanical• Intrcorporeal lithotripsy

– LASER– Pnuematic lithoclast – Ultrasound– ellectrohydrolic

– Push bang stent \ ESWL

• Percutaneous techneque • Perc and pull• Push and perc

• Laproscopic ureterlithotomy• Peritoneal• Extraperitoneal

Definitive treatmentinvasive

• Uretrolithotomy– Upper -------- flank subcostal incision– Mid -------- gibson, grid iron, alaxander– Lower ------- pfennesteil, hemi-pfennesteil, midline– Transvesical ureterolithotomy– Transvaginal ureterolithotomy– Stenting

• Nephrectomy

• BLADDER STONE• Primary• Secondary• Incidence• Child hood, Old age• Types• Oxalate, uric acids, phosphate• Cystine

• Symptoms• Frequency• Pain – stanguary• Haematuria• Interruption of stream • UTI• Investigations• USG• X-ray KUB & IVU• Cystoscopy • Page No. 6

– TreatmentmechanicalMechanico hydraulic

• Litholapexy

• Contraindications to litholapexy– Urethral stricture– Very big stone– Age below 10 years– Contracted bladder– Very hard stone– Vesicolithotomy– ESWL