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URINARY STONE DISEASE DEPARTMENT OF UROLOGY IAŞI – 2013 INTRODUCTION 3rd most common condition of the urinary tract (1 – UTIs, 2 – prostate diseases) stone recurrence rates – 50% within 5 years ! RENAL & 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 & 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 UTIs STONE 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 & 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, UTI Noncalcium Calculi struvite – magnesium, ammonium and phosphate uric acid cystine – autosomal recessive xanthine, indinavir, silicate, triamterene RENAL & URETERAL SYMPTOMS & SIGNS AT PRESENTATION Pain renal colic noncolicky renal pain Hematuria Infection – pyonephrosis, xanthogranulomatous pyelonephritis Fever, Anuria !, Nausea and Vomiting EVALUATION Risk Factors – crystalluria, socioeconomic factors, diet, occupation, climate, family history, medications Physical Examination Imaging Investigations – US, KUB film, IVU, CT (noncontrast spiral), retrograde pyelography, nuclear scintigraphy RENAL & URETERAL 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. INTERVENTION Conservative 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 RENAL & URETERAL 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 RENAL & URETERAL Ureteroscopic Stone Extraction highly efficacious for lower ureteral calculi stone-free rates range from 66-100% lithotrites – electrohydraulic, ultrasonic, laser, pneumatic RENAL & URETERAL Percutaneous Nephrolithotomy choice for large (> 2 cm) calculi, those resistant to ESWL, select lower pole calyceal stones and instances with evidence of obstruction Remaining calculi can be retrieved with flexible endoscopes, additional percutaneous puncture access, follow-up irrigations, ESWL, or additional percutaneous sessions RENAL & URETERAL Open Stone Surgery pyelolithotomy anatrophic nephrolithotomy radial nephrotomy nephrectomy ureterolithotomy BLADDER manifestation of an underlying pathologic condition, including voiding dysfunction (urethral stricture, BPH, bladder neck contracture, neurogenic bladder) or a foreign body irritative voiding symptoms, intermittent urinary stream, urinary tract infections, hematuria, or pelvic pain US electrohydraulic, ultrasonic, laser, pneumatic and mechanical lithotrites cystolithotomy
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