3. INTRODUCTION
Urolithiasis is as old as mankind
The first documented cystolithotomy was described by Sushruta,
an ancient Indian surgeon in almost 600 BC.
5. NON-MODIFIABLE FACTORS
Age:
o For men , fourth to sixth decade.
o For women, bimodal peak in third decade and the
postmenopausal period.
Gender:
Male: Female = 2:1
Ethnic origin: More in White people
Family history: Contributes 2.5 times
6. MODIFIABLE FACTORS
Environmental factors:
More in hot and arid regions
Drugs:
Drugs can predispose to stone formation through metabolic effects
(e.g. corticosteroids, chemotherapeutic agents).
8. PATHOGENESIS
1. Concentration of culprit salts (eg-calcium
and oxalate) overwhelm inhibitory factors
(e.g. citrate, potassium, magnesium, Tamm–
Horsfall mucoproteins, pH changes)
2.Stasis of urine
Precipitation of Crystals
Stone Formation
9. Contd
Acidic pH precipitates the formation of uric acid stones
Alkaline pH precipitates the formation of calcium phosphate
stones.
Stasis stones are usually multiple, round and have a smooth
surface. These are called ‘milk of calcium stones
Infection also contribute to stone formation
11. CALCIUM OXALATE STONES
This is the most common type of stone(60–85%)
Hypercalciuria, hypercalcaemia, hyperoxaluria, hyperuricosuria
and hypocitraturia are known metabolic abnormalities
Primary hyperparathyroidism is the most common disease
Hyperuricosuria causes uric acid crystal formation, especially in
association with acidic urine, over which calcium oxalate crystals
aggregate.
13. CALCIUM PHOSPHATE STONE
Pure calcium phosphate stones are rare.
Common forms seen are apatite and brushite stones.
Apatite is seen with infection and brushite stones are usually
seen with distal RTA
15. URIC ACID STONES
Hyperuricosuria promotes the formation of both calcium oxalate
and uric acid stones.
Uric acid precipitates into crystals in acidic urine and remains
soluble in alkaline urine.
Common in gout and myeloproliferative disorders after cytotoxic
treatment.
16. CYSTINE STONES
1% of stones
Cystinuria is an autosomal recessive inherited disease
Cystine stones are very hard stones as a result of disulphide
bonds and do not fragment with SWL.
18. INFECTION STONES
These are struvite and apatite stones.
Urease-producing bacterial (Proteus, Klebsiella, Serratia or
Enterobacter )
Staghorn calculi are infection stones that grow in a branching
pattern, taking the form of the pelvicalyceal system.
20. CLINICAL PRESENTATION
The presenting symptoms depend on the location, size and type
of stone:
May be asymptomatic
Haematuria
Ureteric colic radiating to groin, scrotum or labia
High grade fever with chills
Calculuria
Urgency and frequency.
Malaise and weight loss
22. INVESTIGATIONS
Urinary examination (Urine RE and CS)
Blood examination
A radiograph of the kidneys, ureters and bladder are good first-
line tests
USG
Non-contrast CT (NCCT) is the investigation of choice for the
diagnosis of stones
Other required tests to roll out the causes or effects
25. METABOLIC EVALUATION
Depends on the risk associated with the recurrence of stone
formation, in child patients and bilateral stone cases.
Urinary examination is done to look at crystals and pH
Serum levels of calcium, phosphorus and uric acid
PTH
26. NON-SURGICAL MANAGEMENT OF STONE
1. Watchful waiting (<5 mm, non-obstructive, asymptomatic, lower
pole renal calculi)
2. Medical expulsive therapy (by Tamsulosin, an α1-adrenergic
adreno-receptor blocker)
3. Extracorporeal shockwave lithotripsy (ESWL)- Acoustic pulse
waves are generated and focused on the stone
28. SURGICAL MANAGEMENT
Indications for surgical intervention:
1. Failure of medical management
2. Impaired renal function
3. Chronic infection – staghorn calculi, matrix calculi
4. High-risk occupation or geographical location – pilots, long-
distance locomotive drivers, sailors.
5. Patient’s preference
29. SURGICAL OPTIONS
Endourology
1. Ureterorenoscopy
2. Retrograde intra renal surgery
3. Percutaneous nephrolithotomy
Non-endourological surgical management
1. Open surgery such as pyelolithotomy and
2. Anatrophic nephrolithotomy
31. Contd
Ureterorenoscopy
long thin scopes
They have working channels that allow for the introduction of
energy sources, graspers and baskets.
A semi rigid URS is usually used with a pneumatic lithotripter or
laser energy device.
32. Retrograde intra renal surgery
A slimmer and more fexible URS
This procedure avoids the morbidity associated with
percutaneous nephrolithotomy (PCNL).
Laser is used as an energy source for stone fragmentation.
Indications for retrograde intrarenal surgery (RIRS),Renal stones
<2 cm, Lower pole calculi,Obesity,Musculoskeletal deformities
(e.g. kyphoscoliosis) and renal anomalies (HSK or pelvic
kidney),Bleeding diathesis.
33. Percutaneous nephrolithotomy
PCNL involves removal of renal stones by creating a track
between the skin and the pelvicalyceal system.
Fluoroscopy or US is used for localisation.
The posterolateral calyx is commonly chosen for entry
US in conjunction with pneumatic and laser lithotripsy
34. PREVENTION OF RECURRENT STONE
DISEASE
General measures advised to all patients include:
fluid intake of more than 2.5 litres per day
Dietary calcium should not be restricted
Supplemental calcium, if necessary, should be taken at meal
times
Reduce intake of animal protein and salt
35. COPMPLICATIONS IF UNTREATED
Urinary tract obstruction
Infectious complications
loss of renal function
Bilateral obstructing ureteric stones in a solitary kidney can
present with anuria
pyelonephritis, pyonephrosis, renal abscess or septicaemia.
Pyelo-enteric or cutaneous fistulae in neglected cases
Nephron loss can occur as a result of recurrent episodes of
infection and obstruction, causing chronic renal failure.
36. CONCLUSION
Although the incidence of urinary stones has declined
progressively owing to the alleviation of poverty and the
improvement in basic nutrition, the modern world is witnessing a
steady increase in the incidence of renal calculi.
Timely intervention can eliminate the suffering of the patients.
