Renal stones are common, affecting around 10-15% of people in the US at some point. Calcium oxalate is the most common type of stone. Stones form due to supersaturation of minerals like calcium and oxalate in the urine. Investigations like ultrasound and CT are used to detect and characterize stones. Treatment depends on stone size and location, and may include medical expulsive therapy, shockwave lithotripsy, ureteroscopy, percutaneous nephrolithotomy, or open surgery. The goal is to remove stones while minimizing complications like bleeding or infection.

1. RENAL STONES
Dr Devendra Jalde, M.Ch Urology
Fellowship in Uro- oncology and Robotics (Tata Memorial
Hosp, Mumbai )
Consultant Urologist and Uro- Oncosurgeon
SNMC and HSK Hospital and Research Centre
Bagalkot

2. EPIDEMIOLOGY
 lifetime prevalence of kidney stone 1% to 15%,
 In the United states- 10% to 15%
 relatively uncommon before age 20 but peaks in incidence in
the fourth to sixth decades of life
 Men are affected two to three times more than women
 higher prevalence found in hot, arid, or dry climates
 directly correlated with weight and body mass index (BMI) in
both sexes

3. CAUSE OF STONE DISEASE
 Supersaturation of urine is the key to stone formation
 Intermittent supersaturation - Dehydration
 Crystal aggregation
 Anatomic Abnormailities – PUJ , horse shoe kidney
 Bacterial Infection
 Defects in transport of Calcium and Oxalate by Renal
epithelia
E.Coli infection increases matrix content in urine . Proteus makes
urine alkaline

4. TYPES OF STONES
 OXALATE (CALCIUM OXALATE)
 PHOSPHATE
 URIC ACID & URATE
 CYSTINE

5. UNCOMMON STONES
XANTHINE STONES
– (Autosomal Recessive . Def of Xanthine Oxidase
leading to Xanthinuria)
SlLICATE STONES
– Rare in humans ( excess intake of Antacid with Mg
Trisilicate. Mostly in cattle due to ingestion of Sand )
MATRIX
- Infection by Proteus - Radiolucent (all calculi have
some amt ( 3%) of matrix but matrix calculus has 65%
Matrix content in calculi)

6. UNCOMMON STONES
TRIAMTERENE
– Anti-hypertensive used with hydroclorothiazide
Indinavir Stones
- Drug to treat AIDS (4 to13%)
Ephedrine or Guifenesin
– Cough medicine - Radiolucent

7. COMPARATIVE INCIDENCES OF FORMS OF URINARY LITHIASIS
Stone analysis in Percentage
Form of Lithiasis India USA Japan UK
Pure Calcium Oxalate 86.1 33 17.4 39.4
Mixed Calcium Oxalate and 4.9 34 50.8 20.2
Phosphate
Magnesium Ammonium 2.7 15 17.4 15.4
Phosphate (Struvite )
Uric Acid 1.2 8.0 4.4 8.0
Cystine 0.4 3.0 1.0 2.8

8. OXALATE (CALCIUM OXALATE)
 Also called mulberry stone
 Covered with sharp projections
 Sharp makes kidney bleed (haematuria)
 Very hard
 Radio - opaque
Under microscope looks like Hourglass or Dumbbell shape if monohydrate and
Like an Envelope if Dihydrate

9. PHOSPHATE STONE
 Usually calcium phosphate
 Sometimes  calcium magnesium ammonium
phosphate or triple phosphate
 Smooth minimum symptoms
 Dirty white
 Radio - opaque
Calcium Phosphate also called ‘Brushite’ appears like Needle shape
under microscope

10. PHOSPHATE STONES
In alkaline urine

enlarges rapidly

take shape of calyces

staghorn 
Struvite can form Stag-horn and appear like coffin lid under microscope

12. URIC ACID & URATE STONE
 Hard & smooth
 Multiple
 Yellow or red-brown
 Radio - lucent (use ultrasound)
Under microscope appear like irregular plates or rosettes
pKa of uric acid 5.75 – at this pH 50% of uric acid insoluble.
If pH falls further - uric acid more insoluble

13. CYSTINE STONE
 Autosomal recesive disorder
 Usually in young girls
 Due to cystinuria -
 Cystine not absorbed by tubules
 Multiple soft or hard –
 Pink or yellow and radio-opaque
Under microscope appears like hexagonal or benezene
ring – ask for first morning sample

15. CLASSIFICATION OF STONES
 Stone size
 Stone location
 X-ray characteristics
Radiopaque, Poor radiopacity , Radiolucent
 Etiology

18. CLINICAL FEATURES
1. Pain in 75 % of cases
“renal colic” if severe and acute
a) Kidney stone
fixed pain in the loin
b) Ureteric stone
pain radiates  loin to groin
Both Stomach & Kidney supplied by celiac ganglion hence Nausea & vomiting
common in renal colic

20. CLINICAL FEATURES (CONTD....)
2) Haematuria
 Can be frank
 Or only found on dip - stick or lab.
3) Pyuria - if infection can have pus in urine

21. INVESTIGATION
 Ultrasound (US) -primary diagnostic imaging tool
Sensitivity of 45% and specificity of 94% for ureteral
stones and a sensitivity of 45% and specificity of
88% for renal stones

23. •
X ray KUB- 90 % are radio-opaque. sensitivity and specificity of
KUB is 44-77%

25.  Non-contrast-enhanced computed tomography (CT)
has become the standard for diagnosing acute flank
pain
 Has replaced intravenous urography (IVU).
 Non-contrast-enhanced CT can determine stone
diameter and density.

29. TREATMENT ALGORITHM FOR RENAL STONE

31. ESWL
Principle
 Shock waves - a special form of sound waves
 consisting of a sharp peak in positive pressure
followed by a trailing negative wave
 generated extracorporeally
 passed through the body to fragment stones.
 change in density and acoustic impedance from
water to calculus results in stone fragmentation

32. SHOCK WAVE GENERATION AND
FOCUSING
 Three primary types of shock wave generators
 Electrohydraulic (spark gap)
 Electromagnetic
 Piezoelectric.
• Stone Localisation
-Fluroscopy
-Ultra sonography

36. CONTRAINDICATIONS
Absolute
 Pregnancy
 Coagulopathy or bleeding
diathesis
 Distal urinary tract obstruction
 Active urinary tract infection
 Renal artery or aortic
aneurysm
Relative
 Obesity
 Uncontrolled hypertension
 Orthopaedic and spinal
deformities
 Cystine or brushite stones

37. COMPLICATIONS
Immediate
Fragment related
Infection
Haemorrhage/haematoma
Adjacent organ injury
Delayed
Reduced Renal function
Hypertension
Stone recurrence

39. PCNL ( PER CUTANEOUS NEPHROLITOTOMY)
Access

43. Biplanar Flouroscopy

49. Rigid
Nephroscope
within the PCS

50. Flexible
Nephroscope
within the PCS

51. MINI PCNL

52. ULTRA MINI PCNL

53. POST PCNL

54. BILATERAL SIMULTANEOUS PCNL

56. COMPLICATIONS
 Bleeding
 Sepsis
 Related to access
 Related to stone removal

57. Access related
 Bleeding
 Loss of tract
 Supra costal access
Hemothorax,
Hydrothorax
 Injury to surrounding
viscera
Stone removal related
 Incomplete clearance
 PCS injury
 Stone dislodgement
Ureter
 Bleeding

59. LAP ASSISTED PCNL

60. Lap Assisted PCNL in Pelvic Kidney

61. FLEXIBLE URETERO-RENOSCOPE (RIRS)
 Flexible, actively deflectable ureteroscopes
 Range from 6.75 to 9 Fr in diameter at the tip
 Able to reach the entire urinary system including the lower
pole of the kidney.

62.  120 to 170 degrees of deflection in one direction and
170 to 270 degrees in the other
 Active dual-deflection ureteroscopes offer two
deflection points in the shaft of the instrument to
facilitate access to all calyces, particularly the lower
pole

65. 

66. OPEN SURGERIES
 < 2 % of the cases for stone disease
 Pyelolithotomy
 Extended Pyelolithotomy and Radial
Nephrolithotomy
 Anatrophic Nephrolithotomy

67. Extended pyelolithotomy. The
renal pelvis is dissected on the
adventitia entering the renal hilum
to expose the bases of the
infundibula. The pelvis is incised
in an open U-shape for stone
removal

68. Anatrophic nephrolithotomy. Vascular clamp on posterior
segmental artery with resulting anatrophic demarcation

69. Extended pyelolithotomy combined
with radial nephrotomies.
Multiple radial incisions of the renal
parenchyma and removal of
caliceal calculi with stone forceps

73. MEDICAL MANAGEMENT
 The aim of the medical management is prevention
of recurrent stones and if possible dissolution of the
stone.
 detailed history and complete investigation

74. The medical therapy consist of two parts:
 dietary modification;
 treatment of individual abnormal stone risk
factors

75. URETERAL CALCULI

76. TREATMENT ALGORITHM FOR URETERAL STONES
Ureteral stone > 20 mm Open ureterolithotomy
Laparoscopic ureterolithotomy
URSL

77. MEDICAL EXPULSIVE THERAPY (MET)
 in informed patients, if active stone removal is not
indicated and size < 8 mm
 α-blockers, Ca-channel inhibitors (nifedipine) and
phosphodiesterase type5 (PDE5) inhibitors
(Tadalafil)
 Tamsulosin showed an overall superiority

78.  Treatment should be discontinued if complications
develop (infection, refractory pain, deterioration of
renal function).
 Side effects include retrograde ejaculation and
hypotension

79. URETEROSCOPY (SEMIRIGID/FLEXIBLE)

80. SEMI-RIGID URETEROSCOPE :
 Tip diameter - 4.5-9.5F (6 F most common)
 Optics - Fiberoptic bundles
 Working channels - One, 2, or 3 (2 channels preferred)
 Accessory length - Average, 40 cm

81. URETEROSCOPY

83. Advantages
Highest success rate
Definitive Rx - No waiting for stone
passage
Disadvantages
More invasive than SWL
Higher complication rate
Requires greater technical expertise

84. OPEN/LAP URETEROLITHOTOMY

86. HIPPOCRATIC OATH
 I will not cut for stone, even for patients in
whom the disease is manifest; I will leave
this operation to be performed by
practitioners, specialists in this art.
 “The Oath in 4th Century BC hold good
even now: It is only rarely needed”

88. Bilateral PCNL

89. THANK YOU