1. O B S T R U C T I V E
U R O P A T H Y &
U R I N A R Y T R A C T
C A L C U L I
A S Y I Q I N
U W A I S
2. Anatomy of urinary system
Kidneys
Ă Excrete the end products of metabolism and excess
water
Ă Endocrine functions:
Ă Producing and releasing erythropoietin which
affects red blood cell formation, renin which
influences blood pressure,
Ă 1,25-hydroxycholecalciferol, which is involved in
the control of calcium metabolism
Ureter
Ă A muscular tube that conveys urine from kidneys to
urinary bladder
Bladder
Ă A reservoir that store and excrete urine
3. Anatomy of kidney
Location
Ă Retroperitoneal
Ă Lies in each side of
vertebral column, T12 â
L3 level
Ă The left kidney is slightly
higher than the right
kidney by half an inch.
Shape
Ă the kidney is bean-
shaped organ and has 2
Poles, 2 borders and 2
surfaces.
Measurement
Ă Length : 10 -12 cm
Ă Breadth : 5 â 7.5 cm
Ă Thickness: >2.5 cm
Ă Weight:
Ă Male: 125 â170 gm
Ă Female: 115â150 gm
Ă Kidney: Body weight: (1:240)
The parenchyma of each
kidney usually drains into
seven calyces, three upper,
two middle and two lower
calyces.
4. Covering of the kidney
1. Kidney
2. Renal capsule
(tough fibrous tissue)
3. Perinephric fat
(collection of extraperitoneal fat)
4. Renal fascia
(Encloses the kidneys and
the suprarenal glands
also known as Gerotaâs
fascia or perirenal fascia)
5. Paranephric fat
(mainly located on the
posterolateral aspect of the
kidney)
5. Relations of kidney
ANTERIOR POSTERIOR
Ă Faces anterolateral
Ă Covered with peritoneum.
Ă Faces posteromedial
Ă No peritoneal covering.
6. Anatomy of ureter
The ureters are muscular
ducts (25-30 cm long) with
narrow lumina that carry
urine from the kidneys to
the urinary bladder
Run inferiorly from the apices of the renal
pelvis at the hila of the kidneys
Courses
Passing over the pelvic brim at the
bifurcation of the common iliac arteries.
Run along the lateral wall of the pelvis
and enter the urinary bladder
Sites of constrictions
Junction of pelvis and ureter
Crossing of pelvic brim
Entrance of urinary bladder
7. Major relations Right ureter:
Psoas major muscle, genitofemoral nerve, duodenum (descending part), branches of
the superior mesenteric vessels, gonadal vessels, common iliac artery, uterine artery,
urinary bladder
Left ureter:
psoas major, genitofemoral nerve, branches of the inferior mesenteric vessels, gonadal
vessels, common iliac artery, uterine artery, urinary bladder
Blood supply Ureteric branches of renal artery, ovarian/testicular artery, ureteric branches of the
abdominal aorta and common iliac arteries, ureteric branches of the superior and
inferior vesical and uterine arteries
Innervation Renal plexus and ganglia, aortic plexus, ureteric branches of intermesenteric plexus, pelvic
splanchnic nerves, superior and inferior hypogastric plexuses
Lymphatic
drainage
Internal iliac, external iliac nodes, common iliac, and lumbar lymph nodes
8. Anatomy of urinary bladder
Location
Ă Male
Ă between pubic symphysis and
prostate inferiorly and distal third
of rectum posteriorly
Ă Female
Ă between pubic symphysis
inferiorly and uterus, vagina
posteriorly
Male Female
Parts: Body, Apex,
Fundus, Neck
Surface: Superior, Inferior, Right
Inferolateral, Left Inferolateral
Angles: Anterior, Inferior,
Posterolateral
9. Anatomy of urinary bladder
Trigone
Triangular area of smooth
muscle
Boarders formed by:
Ă Thickened muscle
between the ureteric
orifices (interureteric
crest)
Ă Thickened muscle
between ureteric orifice
and internal urethral
meatus
Serosa â continuous with perineum
Detrusor muscle â 3 interlaced
muscle layers that aid in micturition
Submucosa â vascular tissue
Mucosa â transitional epithelium
* Individual with obstructed urine outflow usually
come with hypertrophic of the detrusor muscle
10. Arterial supply
(superior vesical arteries)
Ă Male: Superior and
inferior vesical arteries
Ă Female: Vaginal arteries
Venous drainage
Ă Vesical venous plexus.
Ă It is a tributary of the
internal iliac vein
Nerve supply
Ă Sympathetic: T12, L1, L2
innervate trigone,
ureteral opening and
blood vessel
Ă Parasympathetic: fibers
from S2 to S4 innervate
the detrusor muscle
Ă Pelvic splanchnic nerve:
Relay sensory impulses
to the brain from
distension of
specialized stretch
receptor
Innervation of urinary bladder
11. Urethra
Male
Ă Length: 20cm
Ă Parts: Prostatic, Membranous,
Penile/Spongy
Female
Ă Length: 4cm
Ă Opens through the external
urethral opening found
between the labia minora,
anterior to the vaginal opening.
Internal urethral sphincter
Ă Male: Circular smooth fibres
under autonomic control.
Ă Female: Functional sphincter
formed by the anatomy of the
bladder neck and proximal
urethra
External urethral sphincter
⢠has the same structure in
both sexes.
⢠Skeletal muscle, and under
voluntary control.
12. Urethra
Male urethra
Innervation: Prostatic plexus
Lymphatic drainage:
Ă Prostatic and Membranous into
internal iliac nodes
Ă Penile into deep and superficial
inguinal nodes
Female urethra
Vascular: Int. Pudendal, vaginal
arteries/veins
Innervation: Vesical plexus and
Pudendal nerve
Lymphatic drainage:
Ă Proximal â internal iliac nodes
Ă Distal â superficial inguinal
nodes
Prostatic urethra
Ă Receives the ejaculatory ducts
and the prostatic ducts
Ă It is the widest and most
dilatable portion of the urethra.
Ă Supplied by inf. vesical artery
Membranous urethra:
Ă Surrounded by the external
urethral sphincter (voluntary
control of micturition)
Ă It is the narrowest and least
dilatable portion of the urethra.
Ă Supplied by bulbourethral
artery
Penile urethra
Ă Receives the bulbourethral
glands proximally
Ă Dilates to form the navicular
fossa
Ă Supplied directly by branches of
the internal pudendal artery
13. Physiology of micturition
Increased pressure in bladder caused
by accumulation of urine
Stretch receptor in the bladder wall send
signal send signals to the spinal cord (S2 â
S4) via inferior hypogastric nerve
Spinal cord then sends signals through same
plexus â contraction of detrusor muscle and
relaxation of internal urethral sphincter
Cerebral cortex imposes voluntary control
over this reflex as it controls the relaxation of
the external urethral sphincter
Ă â150 ml : 1st urge to void
Ă 150 â 400 ml : bladder radius increased, but urge goes away
Ă 400ml : marked sense of fullness but still controllable
Ă 600ml : painful contraction, micturition inevitable
15. Definition
Ă Functional or structural changes/obstruction in any level of
the urinary tract that impair the normal urine flow
Ă May cause dilatation of the structure proximal to the
obstruction
Ă Obstruction may be in upper or lower urinary tracts and
have corresponding sign and symptoms based on
Ă ĚSite
Ă Degree of obstruction
Ă Duration
21. Complications
Increased backflow pressure
Ă Hydronephrosis
Ă Hydroureter
Ă Renal function impairment
Stagnation of urine
Ă Predispose to infection
Ă Predispose to stone formation
Irritation / abrasion / necrosis
22. Hydronephrosis
Definition
Ă Hydronephrosis is an aseptic dilatation of the kidney caused by obstruction to the outflow of urine
Extramural
Ă Tumour from adjacent
structures
Ă Idiopathic
retroperitoneal fibrosis
Ă Retrocaval ureter
Unilateral
Intramural
Ă Congenital stenosis, narrowing of the PUJ
Ă Ureterocele and congenital small ureteric
orifice
Ă Inflammatory stricture
Ă Neoplasm of the ureter or bladder cancer
involving the ureteric orifice
Intraluminal
Ă Calculus in the pelvis or ureter
Ă Sloughed papilla in papillary
necrosis (especially in diabetics,
analgesic abusers and those
with sickle cell disease) may
obstruct the ureter
23. Bilateral
Bilateral hydronephrosis is usually the result of urethral
obstruction, but the lesions described above may occur on
both sides. When due to lower urinary obstruction, the cause
may be:
Congenital
Ă posterior urethral valves
Ă urethral atresia
Acquired
Ă benign prostatic
enlargement or
carcinoma of the
prostate
Ă postoperative bladder
neck scarring
Ă urethral stricture
Ă phimosis.
24. URINARY
CALCULI
Defined as solid particles in the urinary system
causing pain, nausea, vomiting, hematuria &
possibly chills & fever due to secondary infection.
25. AETIOLOGY
⢠Dietetic
⢠Deficiency in vitamin A
⢠result in hyperkeratosis & desquamation of urinary epithelium which provides debris
for stone formation
⢠Uric acid foods
⢠Mushroom, fish/prawn, beer/wine, bamboo shoot
⢠Inadequate drainage & urinary stasis
⢠Calculi may form whenever urine is stagnates such as in hydronephrosis or
in diverticulum of the bladder
26. ⢠Increased calcium excretion
⢠Prolonged immobilization: skeletal decalcification â â urinary calcium
⢠Hyperparathyroidism â hypercalcemia, hypercalciuria
⢠Lack of stone formation inhibitors
⢠Low levels of citrate & magnesium in the urine make calcium complexes less
soluble promoting calcium oxalate & phosphate stone formation.
⢠Renal infection
⢠Predominant bacteria: staphylococci, proteus, e.coli, klebsiella (urea splitting
organisms). These bacteria produce urease which can alter urine pH creating
alkaline condition which favors stone formation.
27. TYPES OF RENAL CALCULUS
⢠Calcium oxalate (60%)
⢠Three types of stones are described:
â small smooth 'hemp-seed' stones
â small irregular 'mulberry' stones
â small spiculated 'jack' stones
â hard and radio-opaque
â Sharp projection: tend to cause bleeding
â Surface is discolored by altered blood
⢠Phosphate stone (mixture of calcium, ammonia, magnesium) (33%)
â Smooth and dirty white
â Typically large 'staghorn' calculi of pelvicalyceal system and some
bladder stones.
â Radio-opaque
28. ⢠Uric acid and urate (5%)
â Hard, smooth and often multiple and mutlifaceted
â Pure stones are radiolucent
â Most uric acid stones contain some calcium, so they cast a faint
radiological shadow
⢠Cystine calculus (1%)
â Uncommon congenital error of metabolism leads to cystinuria
â Often multiple
â Pure stones are radiolucent
29.
30. RENAL CALCULI
⢠Stones in renal calyces may lie silent for years until complication
(infection) occurs.
⢠50% present at the age of 30-50 y/o
⢠Male:female = 4:3
⢠Sign & Symptom:
⢠Fixed dull ache, worse on movement
⢠Localised at loin or hypochondrium or both
⢠Haematuria (90% have microscopic hematuria)
⢠Ballotable lump in the loin (if hydronephrosis develops)
⢠If obstruction occur at pelvic-ureteric junction, leads to colicky pain
associated with profuse sweating, nausea and vomiting.
31. URETERIC CALCULI
⢠Usually comes from kidney, most pass spontaneously
⢠Clinical features:
⢠Intermittent attacks of ureteric colic. Referred to groin, external genitalia &
anterior surface of thigh.
⢠Impaction at ureteropelvic junction, crossing the iliac artery, juxtaposition of
vas deferens/broad ligament, entering the bladder wall & ureteric orifice.
⢠An impacted stone cause more consistent dull pain
⢠Hematuria
⢠Tenderness and rigidity over course of ureter during abdominal examination
32.
33. BLADDER CALCULI
⢠A primary bladder stone develop in sterile urine; often originates in
kidney.
⢠Secondary stone occurs in presence of:
⢠Infection
⢠outflow obstruction
⢠impaired ladder emptying
⢠foreign body
⢠Male are affected 8 times more frequent than female.
⢠Can be asymptomatic & found incidently
34. SYMPTOMS:-
⢠Increase frequency
⢠Sensation of incomplete bladder emptying
⢠Pain (strangury) (often in spiculated oxalate calculus). Occurs at end of
micturition. Referred to tip of penis/labia majora.
⢠Pain worsened by movement
⢠Child may pull the penis and scream with pain at the end of micturition.
⢠Haematuria at the end of micturition
⢠Interruption of urinary stream (d/t the stone blocking the internal meatus)
⢠Cystitis is common
35.
36. Approach to investigation
Aims of investigation:
⢠To confirm the presence of stone
⢠To locate the stone(s)
⢠To evaluate any deleterious effects of the stone(s) on renal
function and urinary tract morphology
⢠To identify any structural disorders of the urinary tract
acting as local predisposing factors
⢠To identify any metabolic predisposing factors
37. INVESTIGATIONS
⢠X-ray
⢠âKUBâ film shows kidney, ureter &
bladder
⢠Diagnose radiopaque stones (mostly
oxalate stone)
⢠Opacity that maintains its position
relative to the urinary tract is likely to
be calculus
38. ⢠Blood serum level for phosphate, magnesium, calcium, urate
⢠Can use the result to predict types of stone involved.
⢠CT Scan
⢠Excretion Urography (IVU)
⢠Can establish presence & position of calculus & function of other kidney
⢠Need BUSE results 1st as with patient that have renal impairment, they cannot cope with
the IVU contrast
⢠Pt with creatinine level >250 cannot do IVU
⢠If patientâs BUSE not normal, can do retrograde pyelogram to detect the location of
stone
⢠Ultrasound
⢠Most value in locating stones for treatment by extracorporeal shock wave lithotripsy
(ESWL)
⢠Can detect upper hydroureter and hydronephrosis (as complication from stones)
39.
40. MANAGEMENT
⢠Conservative management
⢠Calculi smaller than 0.5cm pass spontaneously unless they are impacted.
⢠If secondary infection occur in upper urinary tract, urgent surgical
intervention is needed.
⢠General principle:
⢠Size of stone (0.5cm = conservative tx) / (>0.5cm = surgical intervention)
⢠Location of stone
⢠Non-invasive treatment considered first â invasive treatment â open
surgery as a last resort (d/t risk of stricture formation)
⢠Preoperative treatment
⢠Antibiotic treatment starts before surgery and continues after wards.
41. â˘Operation for kidney stones:
⢠Modern method of stone removal:
⢠Percutaneous nephrolithotomy
⢠Extracorporeal shock wave lithotripsy (ESWL)
⢠Open surgery
⢠Pyelolithotomy
⢠Nephrolithotomy
42. 1. Percutaneous nephrolithotomy
⢠Endoscopic instrument passed into kidney by percutaneous
technique. Small stones may be grasped under vision & extracted
whole. Large stones are fragmented by ultrasound or laser &
removed pieces. Usually used for stones >2cm size.
⢠Sometimes combined with ESWL in complex (staghorn) calculi.
43. ⢠Extracorporeal shock wave lithotripsy (ESWL)
⢠Crystalline stones disintegrate under the impact of shock waves
produced by the ESWL machine.
⢠A stent is placed in ureter to drain the kidney while stone fragments pas
to avoid bulky stone fragments impacting the ureter causing
obstruction.
⢠Only can be used in stones located at renal pelvis & not more than 2cm
size.
44. â˘Open surgery:
â˘usually for staghorn stone
1. Pyelolithotomy
⢠Indicated for stones in renal pelvis.
2. Nephrolithotomy
⢠Indicated for complex calculus branching into the most peripheral
calyces, & also necessary when adhesions from previous surgery
complicate access to renal pelvis.
45. URETERIC STONE TREATMENT
⢠Pain
⢠NSAIDs (diclofenac & indomethacin)
⢠Indication for surgical removal:
⢠Repeated attacks of pain & stone not moving
⢠Stone is enlarging
⢠Urine if infected
⢠Impacted stone
46. â˘Ureteroscopic stone
removal
⢠A ureteroscope introduced
transurethrally across the
bladder into ureter to
remove stones impacted.
Stones that cannot be
caught are fragmented.
47. ⢠If stone is in upper 1/3 of ureter with size >2cm:
⢠Ureteroscopic cannot be done due to high up location
⢠Push bang technique is preferred. The stone can often be flushed back into
kidney using ureteric catheter.
⢠A J-stent secures the calculus for subsequent treatment with ESWL
⢠Endoscopic stone removal:
1. Ureteric meatotomy
⢠Endoscopic incision with a diathermy knife, to enlarge the opening and free a stone
lodged in the intramural ureter.
2. Dormia basket
⢠Use of wire baskets under image intensifier control. There is a risk of ureteric injury
even with small stones. The technique have been replaced with ureteroscopic
techniques.
48.
49. ⢠Open surgery for ureteric stone:
1. Ureterolithotomy
⢠Open or laparoscopic surgical removal of a stone from the ureter
⢠Used in stone at narrowed site (PUJ)
50. Bladder Stone Treatment
⢠Litholapaxy / Vesicolitholapaxy
⢠Blind lithotrite used to crush bladder stones, an early type of minimally
invasive technique. Now includes optical lithotrite, electrohydraulic
lithothrite, Holmium laser or ultrasound probe.
⢠Used for stones sized >5cm in bladder
⢠Contraindication:
⢠A urethral stricture that cannot be dilated sufficiently
⢠A contracted bladder
⢠A very large stone
51.
52. 2. Percutaneous suprapubic litholapaxy
⢠The best method to use if not possible to carry out
litholapaxy per urethra due to a narrow urethra.
3. Cystolithotomy / Vesicolithotomy
⢠Surgical removal of bladder stones via a lower abdominal
incision
53. Urethral Calculi
⢠Commonly, the stone is a renal calculus that migrate to the urethra via bladder.
⢠Clinical features:
⢠Sudden pain in urethra soon after an attack of ureteric colic
⢠Blockage of flow of urine. If stone small, the stone can often expel from urethral meatus.
Larger stone get stuck.
⢠Sometimes possible to feel a hard lump in urethra
⢠Diagnosis can be confirmed with urethroscopy or bouginage.
⢠Treatment:
⢠A stone in prostatic urethra should be displaced back into bladder (via catheter) and
managed by litholapaxy/suprapubic cystotomy.
⢠A calculi in more distal part are removed by basketing under vision or fragmented in situ
using electrohydraulic.
⢠A calculi in external urethral meatus (narrowest part), should be treated by urethral
meatotomy.
⢠Open removal by external urethrotomy is rarely necessary.
54. SUMMARY OF STONE REMOVAL
Kidney Ureter Bladder Urethra
Percutaneous
Nephrolithotomy
(PNCL)
Dormia Basket Litholapaxy Push Bang
Extracorporeal Shock
Wave Lithotripsy
(ESWL)
Ureteric Meatotomy Percutaneous
Suprapubic
Litholapaxy
Basketing Under Vision
/ Fragmented In Situ
Pyelolithotomy Ureteroscopic Stone
Removal
Cystolithotomy Urethral Meatotomy
Nephrolithotomy Push Bang External Urethrotomy
Ureterolithotomy
55. PREVENTION OF RECURRENCE
⢠Patient should be investigated to exclude metabolic factors.
⢠Urine screened for infection.
⢠Investigations appropriate in bilateral & recurrent stone formers:
⢠Serum calcium, measured fasting on 3 occasions (hyperparathyroidism)
⢠Serum uric acid
⢠Urinary rate, calcium & phosphate in a 24-hour collection
⢠Urine screened for cystine
⢠Analysis of any stone passed.
56. ⢠Dietary advice to those consumed excessive:
⢠Milk products (calcium stone)
⢠Rhubarb, strawberries, plums, spinach & asparagus (calcium oxalate stones)
⢠Eggs, meat & fish (â in sulphur-containing protein) should be restricted in
cystinuria.
⢠Pt with hyperuricaemia should avoid:
⢠Red meats, oďŹal & fish
⢠And should be treated with allopurinol
⢠Drink plenty of water to keep their urine dilute
⢠Drug treatment only eďŹective in those with idiopathic hypercalciuria.
⢠Bendroflumethiazide (5mg) + calcium-restricted diet.
