Urolithiasis
By
Dr. Ahmad A. Al-Sabbagh
Urology Department
Under-graduate courses
• Ten per cent of the population may expect to have an episode of stone disease during their lifetime.
• The upper urinary tract is affected in most cases. Bladder stones are found in a small proportion of men with bladder outflow obstruction.
• The incidence in children remains high in some developing countries.
• The prevalence of stones changes with age and is lower in women, although the male: female ratio is becoming more equal.
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ePIdeMIOlOgy
• Diet
Tomatoes (Oxalate) Livers (Uric Acid) Milk Products (Calcium)
• Metabolic
Ca Stones: Hypercalcemia, Hypercalccuria. Hyperoxaluria
Uric Acid: Gout, Hyperuricosuria
Cystine: Autosomal recessive Disorder
Xanthine Stones: Heriditary xanthinuria
• Infection
Changes the PH of Urine (Urea Splitting Organisms → alkalinization of Urine)
• Obstruction:
Stasis & infection©
eTIOlOgy
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TyPeS Of STOneS
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TyPeS Of STOneS
Calcium Oxalate StonesUric Acid Stone
Cystine Stones Struvite Stone
• Renal stones
Loin pain. The most severe pain occurs when stones are moving,
Asymptomatic stones often are found during radiographic or ultrasound imaging for unrelated reasons
• Ureteric stones
Acute colicky pain, When a ureteric stone has been present for 72 hours, the acute pain subsides and the patient has relatively few symptoms.
Stone Ureter may be impacted in one of the natural ureteric narrowing points (PUJ, when crossed by the common iliac artery, intramural part)
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clInIcal PIcTUre
• Bladder Stones:
Either formed in the bladder (Due to Obstruction) or descending from the upper tract.
Presenting with Frequency, Interruption of urine stream & Maybe terminal hematuria
• Urethral Stones
Mostly Migrating from above, or rarely formed in a urethral diverticulum
Causes interruption of stream then acute retention
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clInIcal PIcTUre
• Infection
• Obstruction
• Migration
• Hematuria
• Retention (if impacted in the urethra or the bladder neck)
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cOMPlIcaTIOnS
• Laboratory:
Urinalysis
Serum Calcium & Uric Acid
Renal Function Tests
• Radiological
KUB – 90% of Stones are Radio-opaque
IVU: Stone appear as filling defect , obstruction & Backpressure
CT Scan : Helpful to diagnose Radiolucent Stones & determining stone density
Ultrasound & Radio-Isotopic Scan
• Instrumental
Endoscopy
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InveSTIgaTIOnS
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InveSTIgaTIOnS
Left Renal Stone
Urinary Bladder Stone
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InveSTIgaTIOnS
Right Upper Ureteric StoneKUB IVP
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InveSTIgaTIOnS
Left Renal Stone - Axial Right Renal Stone - Coronal
Right Renal Stone – 3D Reconstructive
Renal Stones:
• Conservative management of small renal stones
• Extracorporeal shockwave lithotripsy
Effective for treating kidney stones 2 cm in maximum diameter, as long as no obstruction to the passage of stone fragments is present.
• Retrograde Renoscopy
A laser fibre can be introduced through a flexible fibre optic reterorenoscope, which is introduced through the urethra and bladder, and up the ureter to the renal collecting system. Stones 1 cm in diameter can be disintegrated.
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TreaTMenT
Renal Stones:
• Percutaneous nephrolithotomy Stones 2 cm in diameter or more may be treated by percutaneous nephrolithotomy.
Under fluoroscopic control
• Open surgery
Staghorn stones Kidneys that contribute 10% of overall renal function should usually be removed
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TreaTMenT
Ureteric Stone:
• Conservative management
Most stones 5 mm in maximum diameter are likely to pass spontaneously, with high amounts of fluid intake & Diuretics
• Extracorporeal shockwave lithotripsy
Less successful for ureteric stones than renal stones
• Endoscopic ureterolithotomy
With or without stone disintegration
• Open surgery
In case of ureteric pathology, such as stricture
• Laparoscopy©
TreaTMenT
Endoscopic Uretrolithotomy
Bladder Stones
• Endoscopic (Cystolitholapaxy)
In stones less than 2cm
• Surgical (Cystolithotomy):
Larger than 2cm,
Hard stones (Resistent for Crushing)
Stones associated with diverticulum or Bladder neck obstruction (BPH)
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TreaTMenT
• Stone analysis
• Serum Ca & Phosphorus to exclude Hyperparathyroidism
• 24 hour collection of urine for: Ca, Oxalate, Citrate, Uric Acid
• Diet modification (Avoid diet containing the causative crystals) plus high fluid intake
• Modifivation of Urine PH (Alkalinization in uric acid stones by oral NaHCO3 or Acidification in phosphate stones by Vitamin C)
• Prevention & Treatment of UTI
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PrevenTIOn & MeTabOlIc WOrk-UP
Instrumentation & EndoscopyBy
Dr. Ahmad Al-Sabbagh
Urology Department
Under-graduate courses
• A basic understanding of lower urinary tract anatomy and availableinstruments is essential for safe and successful manipulation of the lowerurinary tract. This chapter addresses basic techniques that are used in thepractice of urology.
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ObjecTIve
Indications
• Diagnostic
Collection of urine for culture in females for in order to avoid contamination by skin flora. not necessary in males because clean-catch specimens can be obtained
Measurement of the postvoiding residual urine (can be performed less invasively with ultrasonography)
Instillation of contrast agents into the bladder and urethra for cystourethrography
Urodynamic studies to assess bladder and urethral function
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UreThral caTheTerIzaTIOn
Indications
• Therapeutic
Relief of infravesical obstruction is one of the most common therapeutic indications for urethral catheterization (eg. prostatic enlargement)
To drain the bladder after surgical procedures involving the lower urinary tract
Accurately monitor urinary output.
Intermittent catheterization (by the patient or an assistant) is a common means of managing neurogenic bladder dysfunction
Install medications (eg. Intravesical chemotherapy)
Used as stents after surgery to allow healing of an anastomosis involving urethra.
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UreThral caTheTerIzaTIOn
Types of Catheters
• Straight catheters rubber or latex (Robinson) and polyurethane (Nelaton)
For one-time catheterizations
• Catheters with a curved tip (e.g., coudé catheters)
bypass the male urethra in the presence of prostatic enlargement
• Self-retaining catheters, (Pezzer and Malecot)
the catheter wings maintains the catheter within a hollow viscus.
• Foley-type catheters ,with the balloon mechanism.
Two-way Foley catheters
Three-way catheters they are used when bladder irrigation and drainage are necessary, as, for example, in a patient with bladder hemorrhage
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UreThral caTheTerIzaTIOn
Notes
Catheter size (Outer diameter) is usually referred to using the French (Fr) scale in which each millimeter in diameter is approximately 3 Fr.
One should choose the smallest urethral catheter that will accomplish the purpose of catheterization.
Catheters made from latex or plastic (polyurethane) are not intended for longtime drainage since theses materials react with urine and result in the formation of "encrustations". Consequently catheters made from inert materials such as Silicone are generally recommended whenever prolonged drainage is needed.
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UreThral caTheTerIzaTIOn
Preparation
The patient should be informed of the reason for catheterization and what to expect in terms of discomfort.
Sterilize and drape the external genitalia and surrounding area as for a surgical procedure.
Local anesthesia , such as 2% lidocaine hydrochloride jelly is injected
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UreThral caTheTerIzaTIOn
Technique (Male Patient)
The penis is placed on stretch perpendicular to the body without compressing the urethra.
The catheter is placed in the urethral meatus by holding the catheter at the tip.
Gentle advancement of the catheter is performed
As one approaches the bulbomembranous urethra one can feel the natural resistance of the external sphincter here the patient is asked to take slow, deep breaths to relax and allow easier catheter passage.
If resistance is met, one should not attempt forceful catheter insertion but should apply continuous, gentle pressure and ascertain at what level the potential obstruction exists.
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UreThral caTheTerIzaTIOn
Technique (Female Patient)
After spreading the labia, one can usually identify the urethral meatus easily, and the catheter is placed gently into the bladder
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UreThral caTheTerIzaTIOn
Difficult Catheterization
Difficulty in catheterizing the male patient can result from a variety of causes.
Use catheter introducers
Use filliform followers and catheters
If catheterization is difficult /failed / complicated (false passages) the best solution is to divert urine by Percutaneous suprapubic cystostomy or to catheterize the bladder by the use of urethrocystoscopy (flexible or rigid)
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UreThral caTheTerIzaTIOn
Definition
Direct visualization of the anterior and posterior urethra, bladder neck, and the bladder
Indications
Diagnosis of lower urinary tract disease. (e.g.hematuria, Obstructive & Irritative Voiding Symptoms)
Prior to treatment of many LUT diseases e.g prior to TURP (Transurethral resection of the prostate) or TURBT (Transurethral resection of bladder tumor)
Access to the upper urinary tract for diagnosis and treatment
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cySTOUreThrOScOPy
Equipment
Cystourethroscopy can be performed with either rigid or flexible endoscopes.
Rigid cystourethroscopes consist of a sheath, obturator, bridge, and telescopes.
Constant Fluid irrigation and Illumination to visulalize most hollow viscus in the body and for The bladder several types of irrigant fluid are available (normal saline, distilled water, clycine.
The image from a rigid or flexible endoscope can be transmitted to a TV monitor with the use of a video-camera (video-cystourethroscopy).
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cySTOUreThrOScOPy
Technique
Position of the patient for rigid urethrocystoscopy: Lithotomy position. For flexible urethrocystoscopy: Supine position
The urethral meatus should be inspected
The sheath of the cystourethroscope is generously lubricated
the endoscope can be passed under direct vision with a 0- to 30-degree lens,
Systematic inspection of the entire urethra and bladder should be performed during cystourethroscopy.
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cySTOUreThrOScOPy
Applications
• Cystolitholapaxy:
Description: Endoscopic fragmentation of bladder stone and retrieval of the fragments
Instruments used: the standard urethrocystoscope + one of the stone fragmenting instruments: stone crushing forceps (crocodile forceps) or pneumatic, laser lithotriopsy.
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cySTOUreThrOScOPy
Applications
• Bladder Biopsies
Description: Taking a representative sample from a bladder growth endoscopically by a biopsy forceps. The sampling is done without electric thermal energy.
Instruments used: the standard urethrocystoscope + biopsy forceps (cold cup forceps)+ Bugbee coagulating electrode
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cySTOUreThrOScOPy
Applications
• TURP (Transurethral resection of the prostate)
Description: Resection of the prostatic adenoma by electric thermal energy. The curenthas two properties it could be cutting current i.e. used to cut the gland into small pieces (chips) or coagulating current i.e. used to coagulate the bleeding spots
Instruments used: the standard urethrocystoscope + the resectoscope sheath+ cutting electrode (loop) + coagulating electrode (ball) + Working element
Remarks: Since electric thermal energy is utilized a non-electrolyte irrigant should be used during TURT e.g. water, glycine, sorbitol. Normal saline can not be used.
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cySTOUreThrOScOPy
Applications
• Ureteroscopy and related procedures
The ureteric orifice is identinfied
A guide wire is introduced into the ureteric orifice through the whole ureter and up to the kidney
Dilatation of the intramural ureter is performed by serial telescopic dilators or balloon dilator
The ureteroscope is advanced into the ureter under vision and along the guide wire
Once in the ureter the desired endoscopic procedure could be done e.g stone retrieval, stone disintegration, endoureterotomy (cutting a ureteric stricture), taking a biopsy, resecting a tumour…etc.
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cySTOUreThrOScOPy
Applications
• Nephroscopy and related procedures:
Description: Getting access to the inside of the kidney namely the pelvicalyceal system to conduct a certain procedure. The commonest procedure to be be done via this route is PCNL (percutaneous nephrostolithotomy
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cySTOUreThrOScOPy
Thank You
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