Urinary stones disease, Urolithiasis, Urology.

1. Urolithiasis
Dr. Ahmad Kharrouby
Urology Specialist

2. Urolithiasis (from Greek oûron-urine and lithos-stone) is
the condition where urinary stones are formed or located
anywhere in the urinary system.
Urolithiasis

3. Background

4.  Kidney stones
 Ureteral stones
 Bladder stones
 Urethral stones
Urolithiasis

5.  Urolithiasis is a common
disease that is estimated to
produce medical costs of $2.1
billion per year in the United
States alone.
 Urolithiasis has been a part of
the human condition for
millennia and have even been
found in Egyptian mummies.
Background

6.  Renal colic affects approximately 1.2 million people
each year in USA and accounts for approximately 1% of
all hospital admissions.
 Most active emergency departments (EDs) manage
patients with acute renal colic every day
Background

7. Epidemiology

8.  Urolithiasis occurs in all parts of the world
 A lifetime risk:
 2-5% for Asia
 8-15% for the West
 20% for the Kingdom of Saudi Arabia
 Hot Climate
 Dietary habits
 Hereditary factors
Epidemiology

9.  The lower the economic status, the lower the likelihood
of renal stones
 Most at 20-49 years
 Peak incidence at 35-45 years
 Male-to-female ratio of 3:1
Epidemiology

10. Chemical types and etiology

11.  Four main chemical types:
 Calcium stones
 Struvite (magnesium ammonium phosphate) stones
 Uric acid stones
 Cystine stones
Chemical Types

12.  Calcium stones
account for 75%
of Urolithiasis.
 Radio-opaque
 Multiple factors
and etiologies
 Mostly incidental
Calcium stones

13.  Incidental
 Hyperparathyroidism
 Increased gut absorption of calcium
 Renal calcium leak
 Renal phosphate leak
 Hperuricosuria
 Hperoxaluria
 Hypocitraturia
 Hypomagnesuria
Calcium Stone Known
etiologies

14. Calcium Stone

15.  Account for 15% of renal calculi
 Infectous stones
 Gram-negative rods capable of
splitting urea into ammonium, which
combines with phosphate and
magnesium
 More common in females
 Urine pH is typically greater than 7
Struvite (magnesium ammonium
phosphate) stones

16.  Stag horn stones
are non
obstructive thus
painless
 Slowly growing
 Discovered
incidentally
Struvite (magnesium ammonium
phosphate) stones

17.  Account for 6% of renal
calculi
 Urine pH less than 5.5
 High purine intake eg.
 organ meats
 legumes
 malignancy
 25% of patients have gout
Uric acid stones

18. Uric Acid Stones

19. Uric Acid Stones

20.  2% of renal calculi
 Autosomal recessive trait
 Intrinsic metabolic defect resulting in
failure of renal tubular reabsorption of:
 Cystine
 Ornithine
 Lysine
 Arginine
 Urine becomes supersaturated with
cystine, with resultant crystal
deposition
Cystine stones

21.  Radio-faint
Cystine Stones

22. Prognosis

23.  80 % pass spontaneously
 20% require hospital admission or intervention because
of:
 unrelenting pain
 inability to retain enteral fluids
 proximal UTI
 inability to pass the stone
 renal failure
Prognosis

24. Prognosis
 Recurrence rates after an initial episode of
ureterolithiasis:
 14% at 1 year
 35% at 5 years
 52% at 10 years

25. History

26. History
The presentation is variable.
 Patients with urinary calculi may report
 Pain
 Infection
 Hematuria
 Asymptomatic

27. Silent Kidney stones
 Small nonobstructing stones in
the kidneys only occasionally
cause symptoms.
 If present, symptoms are usually
moderate and easily controlled.

28.  The passage of stones into
the ureter is associated with
classic renal colic because
of:
 subsequent acute obstruction
 proximal urinary tract dilation
 ureteral spasm
 Acute renal colic is probably
the most excruciatingly
painful event a person can
endure
Obstructive ureteral stone

29. Classic Renal Colic
 Acute onset of severe flank pain radiating to the groin
 Gross or microscopic hematuria
 Nausea, and vomiting not associated with an acute abdomen in
50%

30.  Staghorn calculi are often
relatively asymptomatic.
 Branched kidney stone occupying
the renal pelvis and at least one
calyceal system.
 Manifest as infection and
hematuria.
Staghorn stone

31. Acute renal failure
 Asymptomatic bilateral
obstruction
 Solitary Kidney with
obstructive stone

32. Location and characteristics of
pain from ureteral stones
 Depends on the level of
obstruction and its degree:
 ureteropelvic junction
 pelvic brim
 ureterovesical junction

33. UPJ Stone
 Stones obstructing the
ureteropelvic junction may
present with mild-to-severe
deep flank pain without
radiation to the groin

34. Ureteral Stone
 Cause abrupt, severe, colicky pain in the flank and
ipsilateral lower abdomen
 with radiation to the testicles or the vulvar area.
 Intense nausea, with or without vomiting, usually is
present.

35. Upper ureter
 Tends to radiate to the
flank and lumbar
areas

36. Mid Ureter
 Cause pain that radiates anteriorly and caudally.
 Can easily mimic appendicitis on the right or acute
diverticulitis on the left.

37. Distal Ureter and UVJ stones
 Cause pain that tends to radiate into the groin or testicle
in the male or labia majora in the female
 At the ureterovesical junction also may cause irritative
voiding symptoms mimicking cystitis, such as:
 urinary frequency
 dysuria

38. Pain distribution review

39. Bladder Stones
 Usually asymptomatic and are passed relatively easily
during urination.
 Rarely, a patient reports positional urinary retention
(obstruction precipitated by standing, relieved by
recumbency).

40. Phases of an attack

41. Phases of an attack
The entire process typical lasts 3-18 hours
Acute phase: peak in most patients within 2 hours of onset (30 min to 6
hours)
Constant Phase 1- 4 hours maximum 12 hours
Relief phase 1.5-3 hours

42. Physical exam

43.  Dramatic costovertebral angle
tenderness
 unremarkable abdominal evaluation
 painful testicles but normal-appearing
 constant body positional movements
(eg, writhing, pacing)
 Tachycardia
 Hypertension
 Microscopic hematuria
Physical exam

44. Diagnosis

45.  The diagnosis of nephrolithiasis is often made on the
basis of clinical symptoms alone, although confirmatory
tests are usually performed.
Diagnosis

46. Laboratory tests

47.  The recommended based on EUA recommendations:
 Urinary sediment/dipstick test: To demonstrate blood cells
 Serum creatinine level: To measure renal function
Labarotary Testing

48.  May be helpful:
 CBC in febrile patients
 Serum electrolyte assessment in vomiting patients
 24-Hour urine profile on outpatient basis
Additional Lab Tests

49. Imaging studies

50.  Noncontrast abdominopelvic CT scan: The imaging
modality of choice for assessment of urinary tract
disease, especially acute renal colic.
 IV contrast and delayed images might be required in
selected cases
Imaging studies

51.  Renal ultrasonography:
 Renal stone
 Hydronephrosis or ureteral dilation
 Misses 30 % of stones
 Plain abdominal radiograph (flat plate or KUB) misses
40 % of stones
Imaging studies

52. Imaging studies
 IVP (urography) historically, the criterion standard
 In rare select situations:
 Plain renal tomography
 Retrograde pyelography
 Nuclear renal scanning

53. Management

54. Emergency Renal Colic
 IV access to allow :
 Fluid
 Analgesics:
 Paracetamol
 NSAID
 Opiod
 Antiemetic
 In case of infection:
 Urine culture
 Blood culture accordingly e.g. febrile
 Antibiotics

55. Approach Considerations
 In emergency settings what should be kept in mind is the
small percentage suffering renal damage or sepsis.
 These include:
 Evident infection with obstruction
 A solitary functional kidney
 Bilateral ureteral obstruction
 Renal failure

56. Important
 The most morbid and potentially dangerous aspect of
stone disease is the combination of urinary tract
obstruction and upper urinary tract infection.
 Pyelonephritis
 Pyonephrosis
 Urosepsis
 Early recognition and immediate surgical drainage are
necessary in these situations

57. Approach Considerations
 The size of the stone is an
important predictor of
spontaneous passage.
 A stone less than 4 mm in
diameter has an 80%
chance of spontaneous
passage; this falls to 20%
for stones larger than 8 mm
in diameter

58. Approach Considerations
 Hospital admission is clearly necessary when any of the
following is present:
 Oral analgesics are insufficient to manage the pain.
 Intractable vommiting
 Ureteral obstruction from a stone occurs in a solitary or
transplanted kidney.
 Bilateral ureteral obstruction
 Ureteral obstruction from a stone occurs in the presence of
 a urinary tract infection (UTI)
 Fever
 Sepsis
 Pyonephrosis

59. Approach Considerations
 Relative indications to consider for a possible admission
include comorbid conditions
 diabetes
 dehydration
 renal failure
 immunocompromised state
 perinephric urine extravasation
 pregnancy

60. Approach Considerations
Most patients with acute renal colic can be treated on an
ambulatory basis.

61. Approach Considerations
 Aggressive medical therapy has shown promise in
increasing the spontaneous stone passage rate and
relieving discomfort while minimizing narcotic usage

62. Clinic Follow up
 Patients who do not meet admission criteria to be
discharged on medical expulsive therapy from the ED in
anticipation that the stone will pass spontaneously at
home.
 Arrangements should be made for follow-up with a
urologist in 2-3 days.

63. Active medical expulsive therapy
 Paracetamol PRN for pain with or without Codeine
 NSAID PRN for pain
 Oral opiod analogue for severe pain
 Alpha blockers
 Antiemetic PRN for nausea and/or vommiting
 Prednisone 20 mg twice daily for 6 days
 With MET, stones 5-8 mm in size often pass, especially if
located in the distal ureter.

64. Approach Considerations
 An important aspect of medical and preventive therapy is
maintaining a good fluid intake and subsequent high
urinary volume.

65. Emergency Advice
 Patients should be told to return for :
 fever
 uncontrolled pain
 uncontrolled vomiting
 Patients should be discharged with a urine strainer and
encouraged to submit any recovered calculi to a urologist
for chemical analysis

66.  General recommendation not to wait longer than 4
weeks for a stone to pass spontaneously before
considering intervention.
Approach Considerations

67. Approach Considerations
 Larger stones (ie, ≥ 7 mm) that are unlikely to pass
spontaneously require some type of surgical procedure.
 Such patients require mandatory urology follow up

68. Approach Considerations
 About 15-20% of patients require invasive intervention
eventually as emergency or electively due to:
 stone size
 continued obstruction
 Infection
 intractable pain

69. Indications for Surgery
 The primary indications for surgical treatment include:
 Pain
 Infection
 Obstruction
 Indications for urgent intervention:
 Obstruction complicated by evident infection
 Obstruction complicated by acute renal failure
 Solitary kidney
 Bilateral obstruction

70. Surgical options
 Obstruction relief:
 Ureteral stent insertion
 Percutaneous nephrostomy
 Definitive surgical treatment:
 ESWL
 Ureteroscopy
 PCNL
 Open, laparoscopic and robotic
pyelo-lithotomy, ureterolithotomy,
cystolithotomy
 Open anatrophic nephrolithotomy

71. Surgical options
 For an obstructed and infected collecting system
secondary to stone disease
 Emergency surgical relief is required with no contraindications:
 percutaneous nephrostomy for critical patients
 ureteral stent placement for stable patients

72. Surgical options
 The vast majority of symptomatic urinary tract calculi are
now treated with noninvasive or minimally invasive
techniques
 Open surgical excision of a stone from the urinary tract is
now limited to isolated atypical cases

73. Surgical options
 ESWL and ureteroscopy are internationaly recognized as
first-line treatments for ureteral stones.
 The 2005 American Urological Association (AUA)
staghorn calculus guidelines recommend percutaneous
nephrostolithotomy as the cornerstone for management

74. Ureteral Stent
 Guarantees drainage of urine from
the kidney into the bladder and
bypass any obstruction.
 Relieves renal colic pain even if the
actual stone remains.
 Dilate the ureter, making
ureteroscopy and other endoscopic
surgical procedures easier to
perform later.

75. Percutaneous nephrostomy
 Indicated if stent placement is
inadvisable or impossible.
 In particular patients with
pyonephrosis who have a UTI or
urosepsis exacerbated by an
obstructing calculus

76. Extracorporeal shockwave
lithotripsy
 ESWL, the least invasive of the
surgical methods of stone
removal
 Utilizes an underwater energy
wave focused on the stone to
shatter it into passable fragments
 It is especially suitable for stones
that are smaller than 2 cm and
lodged in
 the upper or middle calyx
 the upper ureter

77. Extracorporeal shockwave lithotripsy
 The patient, under varying degrees of anesthesia
 The shock head delivers shockwaves developed from an
 Electrohydraulic
 Electromagnetic
 piezoelectric source

78. Ureteroscopy
 Ureteroscopic manipulation of a
stone is a commonly applied
method of stone removal
 A small endoscope, which may be
 Rigid
 Semirigid
 Flexible
 is passed into the bladder and up
the ureter to directly visualize the
stone

79. Ureteroscopy
 Flexible ureteroscopy allows tackling
of even lower calyceal stones
 Stones are fragmented using
 Swiss lithoclast
 Laser
 Ultrasonic lithotripter
 Stones are retrieved using a stone
basket

80. Percutaneous nephrostolithotomy
 Percutaneous procedures are generally reserved for
large and/or complex renal stones and failures from the
other 2 modalities
 Percutaneous nephrostolithotomy is especially useful for
stones larger than 2 cm in diameter

81. Percutaneous nephrostolithotomy
 In some cases, a combination
of SWL and a percutaneous
technique is necessary to
completely remove all stone
material from a kidney.

82. Open Surgery
 Open surgery has been used less
and less often since the
development of the previously
mentioned techniques
 It now constitutes less than 1% of
all interventions.
 Disadvantages include
 longer hospitalization
 longer convalescence
 increased requirements for blood
transfusion.

83. Approach Considerations
 Metabolic evaluation and treatment at clinic are indicated
for patients at greater risk for recurrence, including:
 multiple stones
 personal or family history of previous stone formation
 stones at a younger age
 residual stones after treatment

84. Medical Therapy for Stone Disease
 Urinary calculi composed predominantly of calcium
cannot be dissolved
 medical therapy is important in the long-term
chemoprophylaxis of further calculus growth or formation

85. Medical Therapy for Stone Disease
 Uric acid and cystine calculi can be dissolved with
medical therapy.
 Suitable option in patients with uric acid stones who do
not require urgent surgical intervention
 Is based on alkalization of the urine.

86. Medical Therapy for Stone Disease
 Sodium bicarbonate can be used as the alkalizing agent
 But potassium citrate is usually preferred because of the
availability of slow-release tablets and the avoidance of a
high sodium load

87. Medical Therapy for Stone Disease
 The dosage of the alkalizing agent should be adjusted to
maintain the urinary pH between 6.5 and 7.0.

88. Chemoprophylaxis
 Prophylactic therapy might include:
 most importantly, augmentation of fluid intake.
 limitation of dietary components
 addition of stone-formation inhibitors or intestinal calcium binders
 avoid excessive salt and protein intake

89. Chemoprophylaxis
Better to base medical therapy for long-term
chemoprophylaxis of urinary calculi on the results of a
24-hour urinalysis for chemical constituents

90. Long-Term Monitoring
 Metabolic evaluation is done by a typical 24-hour urine
determination of:
 urinary volume
 pH
 specific gravity
 Calcium
 Citrate
 Magnesium
 Oxalate
 Phosphate
 uric acid.

91. Long-Term Monitoring
 Most common findings are
 Hypercalciuria
 Hyperuricosuria
 Hyperoxaluria
 Hypocitraturia
 low urinary volume

92. Chemoprophylaxis
 Chemoprophylaxis of uric acid and cystine calculi
consists primarily of long-term alkalinization of urine.

93. Chemoprophylaxis
If hyperuricosuria or hyperuricemia is documented in
patients with pure uric acid stones, allopurinol (300 mg
qd) is recommended

94. Chemoprophylaxis
 Pharmaceuticals that can bind free cystine in the urine:
 D-penicillamine
 2-alpha-mercaptopropionyl-glycine
 Help reduce stone formation in cystinuria.
 Captopril has been shown to be effective in some trials

95. Dietary Measures
 In almost all patients in whom stones form, an increase in
fluid intake and, therefore, an increase in urine output is
recommended.
 This is likely the single most important aspect of stone
prophylaxis
 The goal is a total urine volume in 24 hours in excess of
2 liters.

96. Dietary Measures
 The only other general dietary guidelines are to avoid
excessive salt and protein intake.
 Moderation of calcium and oxalate intake is also
reasonable
 Beware to advice moderation not avoid calcium intake as
it will result in calcium deficiency disorders, most
importantly osteoperosis.

97. Thank you

98. References
• Main references:
• Medscape article nephrolithiasis by J Stuart Wolf Jr, MD, FACS updated
feb 11, 2013
• Campbell-Walsh Urology 10th edition
• Smith and Tanagho's General Urology, Eighteenth Edition
• Images used in this presentation are from different web
based resources
• N.B. The presentation is directed to general medical
audience in the hospital mainly nurses and physicians
with special focus on the acute management.