UrolithiasisBy

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

• DietTomatoes (Oxalate) Livers (Uric Acid) Milk Products (Calcium)

• MetabolicCa Stones: Hypercalcemia, Hypercalccuria. HyperoxaluriaUric Acid: Gout, HyperuricosuriaCystine: Autosomal recessive DisorderXanthine Stones: Heriditary xanthinuria

• InfectionChanges the PH of Urine (Urea Splitting Organisms → alkalinization of Urine)

• Obstruction:Stasis & infection

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Etiology

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Types of Stones

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Types of Stones

Calcium Oxalate Stones

Uric 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 StonesMostly Migrating from above, or rarely formed

in a urethral diverticulumCauses 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:UrinalysisSerum Calcium & Uric AcidRenal Function Tests

• RadiologicalKUB – 90% of Stones are Radio-opaque IVU: Stone appear as filling defect , obstruction

& BackpressureCT Scan : Helpful to diagnose Radiolucent

Stones & determining stone densityUltrasound & Radio-Isotopic Scan

• InstrumentalEndoscopy

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Investigations

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Investigations

Left Renal Stone

Urinary Bladder Stone

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Investigations

Right Upper Ureteric Stone

KUB

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 RenoscopyA 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

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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 & Endoscopy

ByDr. Ahmad Al-

Sabbagh

Urology Department

Under-graduate courses

• A basic understanding of lower urinary tract anatomy and available instruments is essential for safe and successful manipulation of the lower urinary tract. This chapter addresses basic techniques that are used in the practice 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  ©

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 ©

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

TechniquePosition 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 curent has 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

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