URINARYURINARYSTONE DISEASESTONE DISEASE

DEPARTMENT OF UROLOGY IAŞI – 2013

INTRODUCTIONINTRODUCTION

3rd most common condition of the urinary tract (1 – UTIs, 2 – prostate diseases)

stone recurrence rates – 50% within 5 years !

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ETIOLOGY composition = crystals + organic matrix (2-10%) supersaturated urine stone formation

urinary pH ionic strength (concentration of monovalent ions) solute concentration (concentration of 2 ions, solubility

product, formation product) complexation (Na – oxalate, sulfate – Ca)

inhibitors (magnesium, citrate, pyrophosphate, trace metals) nucleation theory – crystals or foreign bodies immersed in

supersaturated urine crystal inhibitor theory – absence or low concentration of natural

stone inhibitors

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nucleation (heterogeneous – epitaxy !), growth & aggregation stone formation

retention in the upper urinary tract (nephrocalcinosis !) mass precipitation theory (intranephronic calculosis) fixed particle theory – Randall plaques, Carr corpuscles

matrix calculi – previous kidney surgery & chronic UTIsSTONE VARIETIES

Calcium Calculi (80-85%) absorptive hypercalciuria – Ca absorption Ca filtered

(glomerulus) PTH tubular reabsorption of Ca Ca ur resorptive hypercalciuria – primary hyperparathyroidism

(parathyroid adenoma) P ur, P sr Ca sr, Ca ur renal damage Ca ur

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renal hypercalciuria – intrinsic renal tubular defect in calcium excretion Ca ur Ca sr PTH (secondary) Ca resorbtion (bone) & absorption (gut) Ca ur

hyperuricosuria hyperoxaluria – primary or enteric (inflammatory bowel disease) hypocitraturia – metabolic acidosis, hypokalemia (thiazide

therapy), fasting, hypomagnesemia, androgens, UTINoncalcium Calculi struvite – magnesium, ammonium and phosphate uric acid cystine – autosomal recessive xanthine, indinavir, silicate, triamterene

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SYMPTOMS & SIGNS AT PRESENTATIONPain renal colic noncolicky renal painHematuriaInfection – pyonephrosis, xanthogranulomatous pyelonephritisFever, Anuria !, Nausea and Vomiting

EVALUATIONRisk Factors – crystalluria, socioeconomic factors, diet, occupation,

climate, family history, medicationsPhysical ExaminationImaging Investigations – US, KUB film, IVU, CT (noncontrast spiral),

retrograde pyelography, nuclear scintigraphy

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Differential Diagnosis – acute appendicitis, ectopic pregnancies, twisted ovarian cysts, diverticular disease, bowel obstruction, biliary stones, peptic ulcer disease, acute renal artery embolism, abdominal aortic aneurysm etc.

INTERVENTIONConservative Observation – spontaneous passage!Dissolution Agents – oral alkalinizing agents (sodium or potassium

bicarbonate and potassium citrate), i.v. alkalinization (sodium lactate), intrarenal alkalinization (sodium bicarbonate)

– acidification – hemiacidrin (Renacidin)Relief of Obstruction – JJ ureteral stent, PNS

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ESWL (Extracorporeal Shock Wave Lithotripsy) electrohydraulic, piezoceramic, electromagnetic approximately 75% of patients with renal calculi (< 1.5-2 cm)

treated with ESWL become stone-free in 3 months

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Ureteroscopic Stone Extraction highly efficacious for lower ureteral

calculi stone-free rates range from 66-100% lithotrites – electrohydraulic, ultrasonic,

laser, pneumatic

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Percutaneous Nephrolithotomy choice for large (> 2 cm) calculi, those

resistant to ESWL, select lower polecalyceal stones and instances withevidence of obstruction

Remaining calculi can be retrievedwith flexible endoscopes, additionalpercutaneous puncture access,follow-up irrigations, ESWL, oradditional percutaneous sessions

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Open Stone Surgery pyelolithotomy anatrophic nephrolithotomy radial nephrotomy nephrectomy ureterolithotomy

BLADDERBLADDER

manifestation of an underlying pathologiccondition, including voiding dysfunction(urethral stricture, BPH, bladder neckcontracture, neurogenic bladder) or aforeign body

irritative voiding symptoms, intermittenturinary stream, urinary tract infections,hematuria, or pelvic pain

US electrohydraulic, ultrasonic, laser,

pneumatic and mechanical lithotrites cystolithotomy