This document discusses urolithiasis (kidney stones). It covers theories of stone formation, epidemiology, risk factors, types of stones, clinical manifestations, diagnostic imaging techniques including ultrasound, CT scans, and cystoscopy, as well as treatments including pain relief, stone removal procedures like ESWL, ureteral stenting, and open surgeries. It also discusses bladder stones including diagnostic evaluation, cystoscopy, and surgical treatment options.

1. UROLITHIASISUROLITHIASIS

2. Theories of Stone FormationTheories of Stone Formation
 A. Nucleation Theory
 B. Stone Matrix Theory
 C. Inhibitor of Crystallization Theory

3. EpidemiologyEpidemiology
 Men > WomenMen > Women
 4 % of population (Germany)4 % of population (Germany)
 Maximum rate at 30 – 50 y.o.Maximum rate at 30 – 50 y.o.
 In children - rareIn children - rare
 GeographyGeography
 EthnologyEthnology

4. RISK FACTORSRISK FACTORS
••Start of disease early in life: <25 yearsStart of disease early in life: <25 years
••Stone containing brushiteStone containing brushite
••Only one functioning kidneyOnly one functioning kidney
••Disease associated with stone formationDisease associated with stone formation::
-- hyperparathyroidismhyperparathyroidism
- renal tubular acidosis (partial/complete)- renal tubular acidosis (partial/complete)
- jejunoileal bypass- jejunoileal bypass
- Crohn’s disease- Crohn’s disease
- intestinal resection- intestinal resection
- malabsorptive conditions- malabsorptive conditions
- sarcoidosis- sarcoidosis
- hyperthyroidism- hyperthyroidism

5. Renal CalculiRenal Calculi
 1 Coral calculus1 Coral calculus
 2 Coral calculi fragment2 Coral calculi fragment
 3 Calculi, which are impregnated with blood pigments3 Calculi, which are impregnated with blood pigments

6. TYPES OF KIDNEY STONESTYPES OF KIDNEY STONES
 There are 4 basic kinds of kidney stones:There are 4 basic kinds of kidney stones:
 Calcium stones (composed of calcium oxalate).Calcium stones (composed of calcium oxalate).
 Uric acid stones.Uric acid stones.
 Struvite stones (composed of magnesiumStruvite stones (composed of magnesium
ammonium phosphate).ammonium phosphate).
 Cystine stone.Cystine stone.

7. Clinical ManifestationsClinical Manifestations
 Acute obstruction of the urinaryAcute obstruction of the urinary
tract may cause renal colic, a formtract may cause renal colic, a form
of severe abdominal pain oftenof severe abdominal pain often
accompanied by nausea andaccompanied by nausea and
vomiting due to celiac ganglionvomiting due to celiac ganglion
stimulation.stimulation.
 Onset is sudden, often during theOnset is sudden, often during the
night or in the early morningnight or in the early morning

8. Clinical ManifestationsClinical Manifestations
 Obstructing calculi in the upper urinaryObstructing calculi in the upper urinary
tract cause an extreme crescendo liketract cause an extreme crescendo like
pain in the flank that generally radiatespain in the flank that generally radiates
laterally around the abdomen to thelaterally around the abdomen to the
corresponding groin and testicles incorresponding groin and testicles in
males and labia major in females.males and labia major in females.

9. Laboratry InvestigationsLaboratry Investigations
 Stone analysisStone analysis: In every patient one stone should: In every patient one stone should
be analysed.be analysed.
 Blood analysisBlood analysis: Calcium Albumin Creatinine Urate: Calcium Albumin Creatinine Urate
 Urinalysis:Urinalysis: Fasting morning spot urine sampleFasting morning spot urine sample
Dip-stick test: pH, Leucocytes/BacteriaDip-stick test: pH, Leucocytes/Bacteria
Cystine test, Ca, P, citrate, urateCystine test, Ca, P, citrate, urate

10. Diagnostic imagingDiagnostic imaging
 UltrasonographyUltrasonography

11. Diagnostic imagingDiagnostic imaging
 Routine examination involves a plain abdominal film of the kidneys, uretersRoutine examination involves a plain abdominal film of the kidneys, ureters
and bladder (KUB)and bladder (KUB)..
 At least 80% of all renal stones are radiopaque and therefore readily visible onAt least 80% of all renal stones are radiopaque and therefore readily visible on
a plain film of the abdomena plain film of the abdomen

12. Plain filmPlain film

13. ExcretoryExcretory urourographygraphy
Excretory pyelography must not be carried out in the following patients - those:Excretory pyelography must not be carried out in the following patients - those:
 With an allergy to contrast mediaWith an allergy to contrast media
 With S-creatinine level > 200 µmol/LWith S-creatinine level > 200 µmol/L
 On medication with metforminOn medication with metformin
 With myelomatosisWith myelomatosis

14. Retrograde pneumopyelographyRetrograde pneumopyelography
Special examinations that can beSpecial examinations that can be
carried out include:carried out include:
 Retrograde or antegradeRetrograde or antegrade
pyelographypyelography
 Retrograde pneumo-pyelographyRetrograde pneumo-pyelography
or cystographyor cystography
 Spiral (helical) unenhancedSpiral (helical) unenhanced
computed tomography (CT)computed tomography (CT)
 ScintigraphyScintigraphy..

15. Diagnostic imagingDiagnostic imaging
 antegrade pyelographyantegrade pyelography retrograde pneumocystographyretrograde pneumocystography

16. Diagnostic imagingDiagnostic imaging
 CCystoscopia shows swallowing of the ureter orifice in lower location ofystoscopia shows swallowing of the ureter orifice in lower location of
the stone, it may also partially project out to the orificethe stone, it may also partially project out to the orifice..

17. СТСТ

18. Differential DiagnosticsDifferential Diagnostics

19. TREATMENTTREATMENT
 ConservativeConservative
 InstrumentalInstrumental
 SurgicalSurgical

20. Pain reliefPain relief
Pain relief involves the administration by various routes ofPain relief involves the administration by various routes of
the following agents:the following agents:
 Diclofenac sodiumDiclofenac sodium
 IndomethacinIndomethacin
 Hydromorphone hydrochloride + atropine sulphateHydromorphone hydrochloride + atropine sulphate
 BaralginBaralgin
 No-spae + AnalgineNo-spae + Analgine
 TramadolTramadol

21. Pain reliefPain relief
 Warm bathWarm bath
 Spasmolytic “cocktails” (with papaverine,Spasmolytic “cocktails” (with papaverine,
spasmalgone, no-spanum, promedole) should bespasmalgone, no-spanum, promedole) should be
taken.taken.
 A high dosage of the cystenal or urolesan (20 dropsA high dosage of the cystenal or urolesan (20 drops
on the piece of sugar) is rather effective at the starton the piece of sugar) is rather effective at the start
of the renal colic.of the renal colic.
 Physical method.Physical method.

22. Pain reliefPain relief
 When pain relief cannot beWhen pain relief cannot be
obtained by medical means,obtained by medical means,
drainage by stenting ordrainage by stenting or
percutaneous nephrostomy (PN)percutaneous nephrostomy (PN)
or stone removal should beor stone removal should be
carried out.carried out.
percutaneous nephrostomypercutaneous nephrostomy

23. Stone removalStone removal
The overall passage rate of ureteral stones is:The overall passage rate of ureteral stones is:
 Proximal ureteral stones: 25%Proximal ureteral stones: 25%
 Mid-ureteral stones: 45%Mid-ureteral stones: 45%
 Distal ureteral stones: 70%Distal ureteral stones: 70%

24. Indications for ActiveIndications for Active Stone removalStone removal
 Active stone removal is stronglyActive stone removal is strongly
recommended in patients fulfilling therecommended in patients fulfilling the
following criteria:following criteria:
 - p- persistent pain despite adequateersistent pain despite adequate
medicationmedication;;
 - p- persistent obstruction with risk ofersistent obstruction with risk of
impaired renal functionimpaired renal function;;
 -- stone with urinary tract infectionstone with urinary tract infection;;
 - r- risk of pyonephrosis or urosepsisisk of pyonephrosis or urosepsis;;
 - b- bilateral obstructionilateral obstruction;;
 - obstructing calculus in a solitary- obstructing calculus in a solitary
functioning kidney.functioning kidney.

26. Percutaneous ProceduresPercutaneous Procedures
 Percutaneous nephrostomyPercutaneous nephrostomy..
 Because of this technique, urologists canBecause of this technique, urologists can
now perform operative procedures withinnow perform operative procedures within
the kidney without using the standard largethe kidney without using the standard large
flank incisions and mobilization of theflank incisions and mobilization of the
kidney.kidney.

27. Ureteral stent

29. ContraindicationsContraindications
 1. hemostasis problems
 2. downstream strictures
 3. no kidney function
 4. acute pyelonephritis
5. spine diseasdes
 6. Chronic kidney insuf. (3-4 stage)
7. pregnancy
 8. tuberculosis

30. Closed Surgical ProceduresClosed Surgical Procedures
 Cystoscopic techniqueCystoscopic technique
With the patient under anesthesia and withWith the patient under anesthesia and with
fluoroscopic control, stones in the distalfluoroscopic control, stones in the distal
ureter can sometimes be removed with aureter can sometimes be removed with a
wire stone basket.wire stone basket.
 UreteropyeloscopyUreteropyeloscopy
Manipulation of small ureteral stonesManipulation of small ureteral stones
under direct vision with a ureteroscope isunder direct vision with a ureteroscope is
a major advance in the management ofa major advance in the management of
ureteral calculi. With this technique, smallureteral calculi. With this technique, small
stones can be easily trapped in a stonestones can be easily trapped in a stone
basket and safely extracted through thebasket and safely extracted through the
dilated ureter.dilated ureter.

32. Extracorporeal Shock WaveExtracorporeal Shock Wave
LithotripsyLithotripsy
 An extracorporeal noninvasive technique that uses shock waves toAn extracorporeal noninvasive technique that uses shock waves to
disintegrate urinary calculi while the patient is immersed in a water bathdisintegrate urinary calculi while the patient is immersed in a water bath
has been tested extensively and is now in clinical use.has been tested extensively and is now in clinical use.
 With this technique, calculi in the upper urinary tract are reduced toWith this technique, calculi in the upper urinary tract are reduced to
fragments, which pass spontaneously from the collecting system andfragments, which pass spontaneously from the collecting system and
bladder in most patients.bladder in most patients.

33. Extracorporeal Shock Wave LithotripsyExtracorporeal Shock Wave Lithotripsy

34. ESWLESWL
2500 - 3000 impulses per procedure
Complications:
Cardiac Arrhythmia, Haematoma,
Infection, Colic
Re-ESWL
about 20 %

35. Indications to surgical operationIndications to surgical operation
 Frequent attacks of the renal colic or persistentFrequent attacks of the renal colic or persistent
pain that disables the patient.pain that disables the patient.
 Disorder of the urine outflow causing theDisorder of the urine outflow causing the
hydronephrotic degeneration of the kidney.hydronephrotic degeneration of the kidney.
 Obturative anuria.Obturative anuria.
 Frequent attacks of the acute pyelonephritis,Frequent attacks of the acute pyelonephritis,
progress of the chronic pyelonephritis thatprogress of the chronic pyelonephritis that
causes renal insufficiency.causes renal insufficiency.
 Total hematuria.Total hematuria.
 Calculous pyonephrosis, apostematousCalculous pyonephrosis, apostematous
pyelonephritis or carbuncle of the kidney.pyelonephritis or carbuncle of the kidney.
 Stone at the sole kidney that causes obstruction.Stone at the sole kidney that causes obstruction.
 Stone in the ureter of the sole kidney that won’tStone in the ureter of the sole kidney that won’t
pass away spontaneously.pass away spontaneously.

36. Open Surgical ProceduresOpen Surgical Procedures
 Pyelolithotomy:Pyelolithotomy:
 Simple pyelolithotomy is used forSimple pyelolithotomy is used for
removal of calculi confined to theremoval of calculi confined to the
renal pelvis.renal pelvis.
 Minimal dissection of the renalMinimal dissection of the renal
sinus is usually needed, andsinus is usually needed, and
exposure of the entire kidney isexposure of the entire kidney is
not required.not required.
 This procedure is not indicated forThis procedure is not indicated for
the removal of entrapped calicealthe removal of entrapped caliceal
stones or large, branched renalstones or large, branched renal
calculicalculi..

37. NephrectomyNephrectomy

38. Open Surgical ProceduresOpen Surgical Procedures
 Ureterolithotomy.Ureterolithotomy.
 There are retroperitoneal,There are retroperitoneal,
transperitoneal and combined surgicaltransperitoneal and combined surgical
accesses. It depends on stone location.accesses. It depends on stone location.
 To remove stone from the superiorTo remove stone from the superior
ureter the Fedorov’s access is used,ureter the Fedorov’s access is used,
from medial ureter – Cuckulidze’s orfrom medial ureter – Cuckulidze’s or
Derev’yanko access is performed, theDerev’yanko access is performed, the
inferior ureter – Pyrogov’s access isinferior ureter – Pyrogov’s access is
needed, the pelvic portion of ureterneeded, the pelvic portion of ureter
may be accessed through themay be accessed through the
suprapubic arcuate incision.suprapubic arcuate incision.

39. Open Surgical ProceduresOpen Surgical Procedures
Nephrectomy NephrolithotomyNephrectomy Nephrolithotomy

40. Bladder stoneBladder stone

41. BLADDER STONESBLADDER STONES
 The composition of bladder stonesThe composition of bladder stones
varies according to the urinary pH andvaries according to the urinary pH and
the concentration of stone-formingthe concentration of stone-forming
elements in the urine.elements in the urine.
 In the USA, calcium oxalate is theIn the USA, calcium oxalate is the
most common constituent, whereas inmost common constituent, whereas in
European countries, uric acid andEuropean countries, uric acid and
urate stones predominate.urate stones predominate.

42. Diagnostic EvaluationDiagnostic Evaluation
 Patients with bladder stones frequently give aPatients with bladder stones frequently give a
history of hesitancy, frequency, dysuria,history of hesitancy, frequency, dysuria,
hematuria, dribbling, or chronic urinary tracthematuria, dribbling, or chronic urinary tract
infection unresponsive to antimicrobial druginfection unresponsive to antimicrobial drug
therapy.therapy.

44. Diagnostic EvaluationDiagnostic Evaluation
 Most vesical stones are radiopaque and apparent on a plain film of the pelvis.Most vesical stones are radiopaque and apparent on a plain film of the pelvis.
 Oblique films may be helpful in differentiating bladder stones from calcifications inOblique films may be helpful in differentiating bladder stones from calcifications in
ovaries, lymph nodes, or uterine fibroids.ovaries, lymph nodes, or uterine fibroids.

45. CystoscopyCystoscopy

46. CystoscopyCystoscopy

47. TreatmentTreatment
 Small bladder stones may be removed bySmall bladder stones may be removed by
transurethral irrigation.transurethral irrigation.
 Larger stones may be crushed by one of a varietyLarger stones may be crushed by one of a variety
of different manual lithotrities and removed fromof different manual lithotrities and removed from
the bladder by irrigation.the bladder by irrigation.
 Ultrasonic and electrohydraulic lithotriptors areUltrasonic and electrohydraulic lithotriptors are
available to fragment large bladder calculi.available to fragment large bladder calculi.

48. TreatmentTreatment
 Stones that are too large to manage transurethrallyStones that are too large to manage transurethrally
and stones associated with prostatic hypertrophyand stones associated with prostatic hypertrophy
should be removed by a suprapubic surgicalshould be removed by a suprapubic surgical
procedure which allows for contemporaneousprocedure which allows for contemporaneous
prostatectomy.prostatectomy.

49. Preventive treatment in calcium stone diseasePreventive treatment in calcium stone disease
 Preventive treatment in patients with calcium stone disease shouldPreventive treatment in patients with calcium stone disease should
be started with conservative measures.be started with conservative measures.
 Pharmacological treatment should be instituted only when thePharmacological treatment should be instituted only when the
conservative regimen fails. Patients should be encouraged to haveconservative regimen fails. Patients should be encouraged to have
a high fluid intake.a high fluid intake.

50. Preventive treatment in calcium stone diseasePreventive treatment in calcium stone disease
 Diet should be of a 'common sense' type - a mixed balanced diet withDiet should be of a 'common sense' type - a mixed balanced diet with
contributions from all food groups but without excesses of any kind.contributions from all food groups but without excesses of any kind.
 The intake of fruits and vegetables should be encouraged because of theThe intake of fruits and vegetables should be encouraged because of the
beneficial effects of fibre. Care must be taken, however, to avoid fruits andbeneficial effects of fibre. Care must be taken, however, to avoid fruits and
vegetables that are rich in oxalate. Wheat bran is rich in oxalate and should bevegetables that are rich in oxalate. Wheat bran is rich in oxalate and should be
avoided. In order to avoid an oxalate load, the excessive intake of productsavoided. In order to avoid an oxalate load, the excessive intake of products
rich in oxalate should be limited or avoided. This is of particular importance inrich in oxalate should be limited or avoided. This is of particular importance in
patients in whom high excretion of oxalate has been demonstrated.patients in whom high excretion of oxalate has been demonstrated.
 The following products have a high content of oxalateThe following products have a high content of oxalate ::
 Rhubarb 530 mg oxalate/100 gRhubarb 530 mg oxalate/100 g
 Spinach 570 mg oxalate/100 gSpinach 570 mg oxalate/100 g
 Cocoa 625 mg oxalate/100 gCocoa 625 mg oxalate/100 g
 Tea leaves 375-1450 mg oxalate/100 gTea leaves 375-1450 mg oxalate/100 g
 Nuts 200-600 mg oxalate/100 g.Nuts 200-600 mg oxalate/100 g.

51. Preventive treatment in calcium stone diseasePreventive treatment in calcium stone disease
 Vitamin C in doses up to 4 g/day can be taken without increasing the risk ofVitamin C in doses up to 4 g/day can be taken without increasing the risk of
stone formation.stone formation.
 Animal protein should not be ingested in excessive amounts. It isAnimal protein should not be ingested in excessive amounts. It is
recommended that the animal protein intake is limited to approximately 150recommended that the animal protein intake is limited to approximately 150
g/day.g/day.
 Calcium intake should not be restricted unless there are very strong reasonsCalcium intake should not be restricted unless there are very strong reasons
for such advice. The minimum daily requirement for calcium is 800 mg and thefor such advice. The minimum daily requirement for calcium is 800 mg and the
general recommendation is 1000 mg/day. Supplements of calcium are notgeneral recommendation is 1000 mg/day. Supplements of calcium are not
recommended except in cases of enteric hyperoxaluria, in which additionalrecommended except in cases of enteric hyperoxaluria, in which additional
calcium should be ingested with meals.calcium should be ingested with meals.

52. Preventive treatment in uric acid stone stone diseasePreventive treatment in uric acid stone stone disease
 The intake of foodstuffs particularly rich in urate shouldThe intake of foodstuffs particularly rich in urate should
be restricted in patients with hyperuricosuric calciumbe restricted in patients with hyperuricosuric calcium
oxalate stone disease , as well as in patients with uricoxalate stone disease , as well as in patients with uric
acid stone disease. The intake of urate should not beacid stone disease. The intake of urate should not be
more than 500 mg/day.more than 500 mg/day.
 Below are examples of food rich in urate :Below are examples of food rich in urate :
 Calf thymus 900 mg urate/100 gCalf thymus 900 mg urate/100 g
 Liver 260-360 mg urate/100 gLiver 260-360 mg urate/100 g
 Kidneys 210-255 mg urate/100 gKidneys 210-255 mg urate/100 g
 Poultry skin 300 mg urate/100 gPoultry skin 300 mg urate/100 g
 Herring with skin, sardines, anchovies, sprats 260-500Herring with skin, sardines, anchovies, sprats 260-500
mg urate/100 g.mg urate/100 g.