URINARY URINARY STONE DISEASE STONE DISEASE DEPARTMENT OF UROLOGY IAŞI – 2013
Jan 19, 2016
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 !
RENAL & URETERALRENAL & URETERAL
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
RENAL & URETERALRENAL & URETERAL
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
RENAL & URETERALRENAL & URETERAL
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
RENAL & URETERALRENAL & URETERAL
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
RENAL & URETERALRENAL & URETERAL
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