1.Upper Urinary Tract Calculi Dr Ahmed Rehman FCPS (URO) Assistant Professes of urology

2. Learning Objectives

Toenumerates 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

3. 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 ofvarying amounts of crystalloids and organic matrix.

4. Urolithiasis

Commonest urological problem in Pakistan

3 rdmost common problem in West after infections and prostate

Ancient timeunder 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

5. 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 knownunknown 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 diseasesa big Q

6. Stones Types

Calcarious calculi8O%

• Calcium oxalate

Non calcarious calculi

• Uric acid5 to !O%

• Cystine 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 (strongurgeassociated withfailure tovoid except a few drops ofblood stainedurine)

• Dull (renal) ache due to hydronephrosis

• Consistant dull pain of impected stone, relieved by rest

Pyuria,

HaematuriaMicroscopic gross

Fever, abscessesInfection

Nausea & vomiting

Acute renal failureanuria

chronic renal failure

Silent loss of kidney

Squamous cell carcinoma of renal pelvis

Perforations with fistula formationexternal, enteric

18. 19. 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

20. 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

21. Complications

Pyonephrosis

Anuria

Abscess

Erosion and extravasation of urine

Urinary fistulae formaation

Loss of kidney / CRF

Septicemia

Cancer

22. Sites of impaction of ureteric calculi

PUJ

Iliac artery crossing

Juxtaposition to vas or broad ligament

Entrance into bladder

Ureteric orifice

23. 24. Investigations

BaselineRFTs

USG hydro ureteronephrosis / stone

X-ray KUBROS

false negative small stone, obscured by gases, bones

IVU/ delayed films

Spiral CT

Retrograde urography

Renal scan

25. Emergency Treatment

Pain relief

Control of Infection

Control of vomiting

Hydration status

26. Treatment of renal calculi

No treatmentESWL >PCNL

• RIRSURS

• Laparoscopic pyelolithotomy

27. Treatment of ureteric calculi

Expectantconservative

Definitive therapy

• Noninvasive

• Minimally invasive

• Invasive

28. 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

29. 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

30. Spontaneous passage

Size

• 1-2mm ---- pass eventually

• 4-5 mm --- 40-50%

• >6mm----