Urinary Tract Urolithiasis

Introduction

Found in Egyptian mummies. Stone surgeries earliest procedures described. Affects 1 - 5 % of the population. 10 – 20 % will require surgical intervention.

التصريف لمن عجز عن التأليف

(324-404 -936هـ / م1013 )

(Albucasis) الزهراوي

النساء لدى المثانة حصى إزالة عمليات أجرى من أولالمهبلية .بالجراحة

في الشرج إلى البول مجرى حول من أول كان كماالنساء في المهبل وإلى http://rowad.al-islam.com الرجال،

http://www.ummah.net/history/scholars/el_zahrawi/

Objectives• Epidemiology• To review the physical chemistry

of stone formation.• To develop a strategy for

diagnosis and management of a patient with a kidney stone.

• To rationalize a practical approach to stone prevention.

Epidemiology

• Annular incidence rate as high as 1%

• Lifetime risk– 10-20% in men– 5-10% in women.

• Most common type of stone is calcium oxalate containing stone (75%)

Epidemiology

• Recurrence rate – 15% in the 1st year .– 35% in 5 years .

• Common in white men > black.

• Occurs between 20-50 age group.

• M : F 3 : 1 in adult.

1989 Abdel Haleem

Chemical Composition of Stones

0

10

20

30

40

50

60

70

80

Calcium Struvite Uric Acid Cystine Others

%

Male : female = 3:1 Age 20-30 yearsMale : female = 5-2:1 Age 20-30 years

In SAX 2.5 in Saudis

Type and Causes of Stones

1. Calcium stones ( 75% ).

2. Infection stones (Struvite ) ( 15% ).

3. Uric acid stones (5 –10%)

4. Cystine stones ( 1% ).

1. Calcium stones ( 76% ).

2. Uric acid stones ( 20% ).

3. Infection stones ( Struvite ) ( 3-6% ).

4. Cystine stones ( 1% ).

In SA 1990 Abomelha

Stone Recurrence Rates

0

10

20

30

40

50

60

70

80

Italy Sweden Australia Alaska SA

%%

Pathogenesis of Stone Formation

Excessive Low inhibitory supersaturation activity

Randall’s Plaque

X100

What is this ?

Bilateral Staghorn Calculi

KUB

Infection stones

• Magnesium – ammonium – phosphate .• Triple phosphate stones .• Alkaline urine .• Urea – splitting bacteria .

• Proteus ***.

• Pseudomonas .

• Klebsiella .

• Staph

• ?? E. coli

?

Uric acid stone

• Product of purine metabolism .• Setting of stone formation :

• Low urine volumes .

• Acidic urine .

• High level of urinary uric acid .

• Radiolucent stone .

Symptoms of kidney stone

No symptoms

Renal colic

The Kidney Stone Scream

CLINICAL HISTORY Symptoms of a Kidney Stone

Sudden onset of severe pain

Starts in the back, radiates to the front & to groin

NauseatedBlood in urineIrritative voiding

CLINICAL HISTORYDetails

• Personal Hx:– Age at onset – Sex – Occupation – Geographic residence

• Fluid intake• Diet • PSHx:

• Interventional procedures, surgeries and • Stone episodes / Previous stone composition

• PMHx– Co-morbidities: PTH, Gout, bowel disease, Urinary tract

infections, renal disease

• Drug Hx: vitamins

• Family history

Physical exam

Appearance In pain Writhing or pacing Pale and sweating

VS Pulse, RR and BP elevated Temp normal

Abd exam Tender flank and costovertebral angle Ext genitalia and DRE (usually normal)

Work up of any Work up of any stone- forming stone- forming

patientpatient

Laboratory Studies

Blood CBC Creatinine Electrolytes

Urine Urinalysis +/- Culture Strain urine

Detailed: LAB EVALUATION SerumSerum• Calcium • Phosphorus • Uric acid • Creatinine • Alkaline phosphatase• PTHUrineUrine • Urinalysis • Culture • Fasting pH • 24-hr volume • Cyanide nitroprusside test

Urine chemistryUrine chemistry (24-hr volume with creatinine ) •   Calcium •   Phosphorus •   Uric acid •   Oxalate •   Cystine •   Citrate •   Sodium •   Magnesium Stone analysisStone analysis

Investigations of Stoneformers

StoneAnalysis for

composition

ImagingKUBIVPUSCT

• Ix– imaging

Calcium oxalate monohydrate (whewellite)—also called “mulberry stone

Uric acid calculus—

also called “jackstone

Staghorn calculus—magnesium ammonium phosphate (struvite).

Concentric character of magnesium ammonium phosphate struvite

Sites of Ureteric Stone Impaction

Ureteropelvic junction (UPJ)

Over the iliac vessels

Ureterovesical junction (UVJ)

5mm Calcification L3-4 Left

KUB

5mm Stone L3-4 Left

Ltretrogradepyelogram

No Stone Seen

KUB IVP

Delayed excretion at 3 min

3 minpost-injection

Mild Ureteric Dilatation at 10 min

10 minpost-injection

1.8 cm Proximal Left Ureter

Ultrasound

Stone Upper Right Ureter

CT Scan

Stone Upper Right Ureter

CT Scan

Triage Strategy

Inpatient Urology Consult

Poor pain controlInfectionSingle/both kidneys

blockedLarge stone Co-morbidities

Outpatient ConsultPush fluidsOral

analgesics/antiemeticsTamsulosin (Omnic)Strain urineReturn if increased pain

or feverFollow-up ± further

imaging

Management of Renal Colic

Intravenous fluids Adequate narcotic analgesia Adequate anti-emetics Strain urine Image to define diagnosis Triage to urology

– in/outpatient

• Acute management .• Diagnosis of the underlying pathology .

– 1st stone will have limited screening – Recurrent stone patient more extensive workup.

Urological ManagementActive surveillanceEndoscopic urologyPercutaneous urologyExtracorporeal

shockwave lithotripsy (ESWL)

Open urology/Lap

Right Ureteric Stent

Ureteroscopy and intracorporeal laser lithotripsy

Renal Access for Percutaneous Nephrolithotomy

Successful Lower Calyceal Access

Percutaneous Kidney Surgery

First Generation Lithotriptors

Contemporary ESWL Unit

Contemporary ESWL Unit

Goal of ESWL

Pre-op 1st Rx 2nd Rx

Open Stone Surgery

Nephrolithotomy

Pyelolithotomy

Ureterolithotomy

Cystolithotomy

Questions Regarding Investigations of SF

• Where?

• Why?

• Who?

• What?

• When?

Stone Management Team

Dietician

Imaging

Lab

Urologist

Patient

Management of urolithiasis

• Revolution.

• 15-30% of symptomatic stone will require surgeries.

• Stone < 7 mm to be given 4-8 weeks to pass on their own with alpha blocker and pain medication.

• Stone >10 mm unlikely to pass spontaneously .

Management of urolithiasis

• Indication for intervention :

•High grade urinary obstruction .•Infection •Uncontrolled pain •Impaired renal function

Management of urolithiasis

• Stone dissolution :

• Only uric acid and cystine stones .• If surgery needed it is needed .• Oral alkalinization for several weeks.• Direct irrigation of the stone with

alkaline solution is successful.• Failure to dissolve will require surgical

intervention .

Urinary Risk Factors

Calcium Oxalate

Low volume Hyperoxaluria Hypercalciuria

Fixed pH Hyperuricuria Low inhibitors

Calcium OxalateCalcium Oxalate

Manipulation of Urinary Risk Factors

Abnormality Dietary Rx Drug Rx

Low volume > Fluids > FluidsHyperoxaluria < Oxalate B6

> CalciumHypercalciuria < Sodium Citrate < Animal protein Thiazide

> Fibre Hyperuricosuria < Purine Allopurinol Fixed low pH < Animal protein Citrate

Bicarbonate

Fixed high pH NA NH 4Cl (?) Low inhibitors ? Citrate

Pentosan

Stone Prevention

>2.5 L urine per day

( pt with hypercalciuria).

except infective stone

(uric acid )

Summary Determine type of stone Measure urinary risk

factors Manipulate fluid/diet Arrange follow up Consider drugs

من وصايا الزهراوي المأثورةأوصيكم يا بني عن الوقوع فيما فيه الشبهة عليكم، فإنه قد يقع

إليكم في هذه الصناعة ضروب من الناس بضروب من ،األسقام

فمنهم من قد ضجر بمرضه وهان عليه الموت لشدة ما يجده من ،سقمه

.. ومنهم من قد يبذل ماله ويعينك به رجاء للصحة�باعدوا ألبتة بينكم وبين من هذه صفته ،فال ينبغي أن ُت

،وليكن ُتحذركم أشد من رغبتكم وحرصكم�قدموا على شيء من ذلك إال بعد علم يقين يصبح عندكم بما وال ُت

،ُتصير إليه العاقبة المحمودةواستعملوا في عالج مرضكم ُتقدمة المعرفة واإلنذار إلى ما ُتئول

،إليه السالمةفإن لكم في ذلك عونا على اكتساب الثناء، والمجد والذكر

.الكريم