upper urinary tract calculi
DESCRIPTION
thanx to dr.ahmed rehmanTRANSCRIPT
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
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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
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• 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