Upper urinary tract calculi
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Upper urinary tract calculi

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thanx to dr.ahmed rehman

thanx to dr.ahmed rehman

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Upper urinary tract calculi Upper urinary tract calculi Presentation Transcript

  • Upper Urinary Tract Calculi Dr Ahmed Rehman FCPS (URO) Assistant Professes of urology
  • Learning Objectives
    • To enumerates factors involved in stone formation and describe their role
    • To describe clinical features of urolithiasis
    • To name investigations to workup a case of calculus
    • To describe different stages of disease
    • To choose suitable treatment option for each stage of disease
  • Urolithiasis
    • Urinary stones are pieces of solid matter formed in the urinary tract out of normal or abnormal urinary constituents.
    • Calculi are polycrystalline aggregates composed of varying amounts of crystalloids and organic matrix.
  • Urolithiasis
    • Commonest urological problem in Pakistan
    • 3 rd most common problem in West after infections and prostate
    • Ancient time under developed world common stone was bladder
    • Now the trend has shifted to kidneys, thanks to urbanization and civilization
    • Roughly 3 to 1O% people suffer with a roughly 5O % recurrence in 5 years
    • Merits higher in Pakistan, than in the West, as a cause of ESRD
  • Upper Urinary Tract Calculi Etiology
      • Complex and not exactly known
      • Only1O to 15 % cases cause can be found
      • Rest labeled idiopathic
      • Is not a single disease entity, end result of many known unknown factors
      • Has been called a MULTI SYSTEMIC disease rather than a mere urinary problem
        • Diseases of other systems set environment ripe for pathological uncontrolled biomineralization( stone formation, which in that case is a manifestation or complication of that disease.
      • A disease or a symptom of diseases a big Q
  • Stones Types
    • Calcarious calculi 8O%
      • Calcium oxalate
    • Non calcarious calculi
      • Uric acid 5 to !O%
      • Cystine <2%
      • Xanthine
      • Phosphate ammonium magnesium phosphate 5 to 1O%
    • Mix calculi
    • Matrix calculi
    • Indinavir, silicate, triamterene
  • Etiological factors
    • Heredity
    • Age & sex effect
    • Dietary factors
    • Climatic & seasonal factors
    • Geography
    • Water intake
    • Occupation
    • Social class
    • Obstruction stasis congenital and acquired
    • Infections
    • Altered urinary solutes and colloids
      • Dehydration
      • Increase conc of promoters or decrease conc of inhibitors
      • Metabolic disorders
      • Hyperparathyroidism
      • Prolonged immobilization
    • Heredity
      • Renal tubular acidosis,
      • cystinuria
      • xanthinuria
    • Age
      • Peak age 2O to 4O
      • Extreme ages association with obstruction
    • Sex
      • More common in males 3 to 1
    • Climatic & seasonal factors
      • Dry hot plainsdeserts and cold high altitudes = perspiration, water intake
      • Sunlight exposure vitamin D activation
    • Geography
      • Well defined stone belts environmental factors
    • Water intake
      • Low intake as opposite to perspiration, losses, requirement
      • Mineral content zinc very hard and very soft water
    • Occupation
      • Sedentary , managerial professionals
    • Affluent Social class animal protein
    p
    • Dietary factors
        • High protein diet
        • High Salt content
        • Low water intake
        • High calcium, oxalate and phosphate diet
        • Low dietary citrate
        • Vitamin A deficiency bladder calculi
        • Fluid intake
  • Steps of stone formation
    • Precipitation crystallization
    • Saturation, Super saturation renal papilla
    • Nucleation
      • Homogeneous & heterogeneous
      • Free & Fixed particle nucleation
    • Crystal retention, Crystal growth and aggregation concretions, microliths
    • Role of matrix nidus, glue, inhibitor, bystander
    • Inhibitors & promoters of crystallization. metastable
  • Theories of stone formation
    • Crystallization Precipitation theory
    • Nucleation theory
    • Crystal inhibition theory
    • Fix particle theory
      • Randalls plaque renal papilla
      • Carr microliths lymphatics
    • Theory of mass precipitation intranephronic precipitation
    • Matrix nucleation theory
  • Calcium calculi etiology
    • Hypercalciuria
      • Absorptive
      • Resorptive Hyperparathyroidism
      • Renal induced
      • Idiopathic
    • Hyperuricosuria
    • Hyperoxaluria
      • Chronic diarrhea
      • Enteric
      • Primary
    • Hypocitraturia
    p
    • Hypercalcemic nehrolithiasis
      • Primary hyperthyroidism
      • Malignancy associated hypercalcemia
      • Granulomatosis sarcoidosis
      • Hyperthyroidism
      • Glucocorticoid induced hypercalcemia
      • Pheochromocytoma
      • Immobilization
    • Hypomagnesuria
    • Renal tubular acidosis and calcium phosphate stones
    • Gout and uric acid stones
    • Inborn errors of metabolism
  • Ureteri calculi Origion
    • Nearly always take birth in kidney
    • Exceptions
          • Stones in ureterocele
          • Stones in kinked / dilated ureters
          • Stones in strictured / stenosed ureters
          • Stones in ureteric diverticulae
          • Stones in schistosomiasis affected ureters
          • Encrustations on foreign bodies
            • Stents
            • sutures
  • Clinical Features
    • No symptoms
    • Pain
      • Renal pain renal angle > upper abdomen,
      • Ureteric colic
            • Acute, agonizing pain
            • Rolls around as excruciating sharp pain supperimposed uppon a background of continous discomfort (peristalsis pushing stone down).
        • Upper ureter = similar to renal colic
        • Lower down = loin to groin, genitalia, anterior aspect of thigh, retracted tender testis
        • Intramuural = ref to tip of penis,
            • strangury (strong urge associated with failure to void except a few drops of blood stained urine)
      • Dull (renal) ache due to hydronephrosis
      • Consistant dull pain of impected stone, relieved by rest
    • Pyuria,
    • Haematuria Microscopic gross
    • Fever, abscesses Infection
    • Nausea & vomiting
    • Acute renal failure anuria
    • chronic renal failure
    • Silent loss of kidney
    • Squamous cell carcinoma of renal pelvis
    • Perforations with fistula formation external, enteric
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  • Clinical Examination
    • No significant sign
    • Some tenderness and rigidity over renal angle or some part of course of ureter
    • Distress,
    • Tachycardia, Fever, hypotension sweating
    • Palpable kidney
  • Differential diagnosis
    • Skin / subcutaneous tissues ---- Herpes
    • Muscles – spasm, psoss abscess
    • Bones – caries spine, psuedo renal (Radicular ) pain
    • Lungs - Puemonia, plurecy,effusion
    • Liver – hepatitis, abscess,
    • GB – cholecystitis
    • Appendicitis, typhlitis, large bowl obsruction
    • Salpingitis, ectopic pregnency
    • Ovarion cyst / tortion
    • PID
    • Splenomegaly
    • Hydrnephrosis / renal mass, pyelonephritis
    • Adrenals diseass
    • Mural / extramural ureteric obstruction
    • APD / Inferior wall MI
    • Testicular pain, varicocele
    • malingering
  • Complications
    • Pyonephrosis
    • Anuria
    • Abscess
    • Erosion and extravasation of urine
    • Urinary fistulae formaation
    • Loss of kidney / CRF
    • Septicemia
    • Cancer
  • Sites of impaction of ureteric calculi
    • PUJ
    • Iliac artery crossing
    • Juxtaposition to vas or broad ligament
    • Entrance into bladder
    • Ureteric orifice
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  • Investigations
    • Baseline RFTs
    • USG – hydro ureteronephrosis / stone
    • X-ray KUB ROS
    • false negative – small stone, obscured by gases, bones
    • IVU/ delayed films
    • Spiral CT
    • Retrograde urography
    • Renal scan
  • Emergency Treatment
    • Pain relief
    • Control of Infection
    • Control of vomiting
    • Hydration status
  • Treatment of renal calculi
    • No treatment <4mm
    • Conservative treatment < 5 to 8mm
    • Noninvasive treatment ESWL stenting
    • Conventional treatment
            • Pyelolithotomy,
            • Extended pyelolithotomy
            • Nephrolithotomy
            • Nephrectomy
    • Minimal invasive treatment
      • PCNL
      • Sandwich therapy PCNL >ESWL >PCNL
      • RIRS URS
      • Laparoscopic pyelolithotomy
  • Treatment of ureteric calculi
    • Expectant conservative
    • Definitive therapy
      • Noninvasive
      • Minimally invasive
      • Invasive
  • Expectant treatment
    • Relief of pain
      • Roll of NSAIDS
      • Roll of sposmolytics
      • Roll of IV fluids
      • Roll of diuretic
      • Roll of steroids
      • Roll of edema reducing agens
      • Roll of rest / exercise
      • Roll of urinary alkalization
      • Roll of antibiotics
      • Roll of chemotherapy
      • Roll of homeo therapy / indegenous medicine
    • assessment of renal function & back pressure
    • Follow up -- 4-6 weeks
  • Indications to abandon conservative therapy
      • No progress
      • Intractable pain
      • Stone enlarging / too large a stone
      • Fever (UTI)
      • Oligurea / anurea / Renal function deterioration
        • complete obstruction
          • Bilateral
          • Unilateral – solitary kidney
      • Profession
  • Spontaneous passage
    • Size
      • 1-2mm ---- pass eventually
      • 4-5 mm --- 40-50%
      • >6mm ---- <5%
    • Site
    • shape
    • Degree of hydronephrosis / impection
    • Obstructive lesion
  • Definitive treatment Noninvasive
    • ESWL in situ (with out push back)
      • Upper ureter – suppine
      • Lower and mid --- prone
      • Countraindication : impected stone
          • Infected system ( stenting or PCN followed by definative treatment )
          • Distal obstruction
  •  
  • Definitive treatment minimally invasive
    • Endoscopic removal
      • Dormia basket ============NOT USED NOW
      • Ureteric metotomy- transurethral ureterolithotomy
      • Uretro renoscopy
        • Mechanical
        • Intrcorporeal lithotripsy
          • LASER
          • Pnuematic lithoclast
          • Ultrasound
          • ellectrohydrolic
      • Push bang stent ESWL
    • Percutaneous techneque
        • Perc and pull
        • Push and perc
    • Laproscopic ureterlithotomy
        • Peritoneal
        • Extraperitoneal
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  • Definitive treatment invasive
    • Uretrolithotomy
      • Upper -------- flank subcostal incision
      • Mid -------- gibson, grid iron, alaxander
      • Lower ------- pfennesteil, hemi-pfennesteil, midline
      • Transvesical ureterolithotomy
      • Transvaginal ureterolithotomy
      • Stenting
    • Nephrectomy
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    • BLADDER STONE
    • Primary
    • Secondary
    • Incidence
    • Child hood, Old age
    • Types
    • Oxalate, uric acids, phosphate
    • Cystine
    • Symptoms
    • Frequency
    • Pain – stanguary
    • Haematuria
    • Interruption of stream
    • UTI
    • Investigations
    • USG
    • X-ray KUB & IVU
    • Cystoscopy
    • Page No. 6
          • TreatmentmechanicalMechanico hydraulic
    • Litholapexy
    • Contraindications to litholapexy
          • Urethral stricture
          • Very big stone
          • Age below 10 years
          • Contracted bladder
          • Very hard stone
          • Vesicolithotomy
          • ESWL