Nephrolithiasis (kidney stones) is a disease affecting the urinary tract. Kidney stones are small deposits that build up in the kidneys, made of calcium, phosphate and other components of foods. They are a common cause of blood in urine. Kidney stone formation may result when the urine becomes overly concentrated with certain substances. These substances in the urine may complex to form small crystals and subsequently stones. A number of blood and urine tests will be required to detect the presence of infection and test the function of the kidneys

1. Dr. Rabindra Tamang
Junior Resident
BPKIHS, Dharan
Nepal

2. Contents
 Introduction
 Types of nephrolithiasis
 Diagnostic evaluation of nephrolithiasis
 Conservative management
 Surgical management
 Conclusion
 References

3. Introduction
 One of the most common afflictions of
modern society
 The lifetime prevalence of kidney stone disease is
estimated at 1% to 15%
 The age of peak incidence in men 30 to 69 years and in
women 50 to 79 years.

4. Types of renal calculi

5. Diagnostic evaluation
 Must identify associated metabolic disorders
responsible for recurrent stone disease.
 Medications
 Dietary excesses, inadequate fluid intake or excessive
fluid loss

6. Indications for Metabolic Evaluation
 Strong family history of stones
 Recurrent stone formers
 Intestinal disease (particularly chronic diarrhea)
 Solitary kidney
 Renal insufficiency
 Anatomic abnormalities

7.  Pathological skeletal fractures
 Osteoporosis
 History of urinary tract infection
with calculi
 Personal history of gout
 Infirm health (unable to tolerate repeat stone
episodes)
 Stones composed of cystine, uric acid, struvite

8. Multichannel blood screen
 Basic metabolic panel (sodium, potassium, chloride,
carbon dioxide, blood urea nitrogen, creatinine)
 Calcium
 Intact parathyroid hormone
 Uric acid

9. Urine
 Urinalysis
 pH > 7.5: infection lithiasis
 pH < 5.5: uric acid lithiasis
 Sediment for crystalluria
 Urine culture
 Urea-splitting organisms: suggestive of infection
lithiasis
 Qualitative cystine

10. Microscopy

11. Radiological investigations

12. X-ray KUB
 Most common imaging technique
 Used in the follow up of patients during or after
treatment for stones, particularly after ESWL.
 Limited value if the stone is radiolucent.

13. Intravenous pyelography:
 Outdated
 Uses :
 Radiolucent stones,
 Anatomic abnormalities
 All urologists can interpret the
x rays.

14. Ultrasonography
 No radiation exposure
 Detects radiolucent stones
 Adjunt in ESWL
 Inefficient in detecting small stones

15. CT urography
 Investigation of choice in the
imaging of kidney stones.
 Sensitivity : ~95%
 Specificity: ~98%
 Information regarding the composition of stones
 Confirms the diagnosis in which USG in equivocal

16. MRI
 Provide 3D image without radiation
 Lower accuracy and
 Expensive

17. Stone analysis
 Direct further management
 Struvite: infection lithiasis.

18. Conservative medical management
 Made for all patients regardless of the underlying
etiology of their stone disease
 Calculi smaller than 0.5 cm pass spontaneously

19. Fluid recommendations
 Volume:
 daily urine output of 2 L (Borghi et al, 1999).

20.  Carbonated water  protection against recurrent
stone formation.
 Citrus Juices  provide increased urinary volume and
increased urinary citrate excretion.

21. Dietary Recommendations
 Decreased animal protein intake.
 Sodium restriction
 Combined : stone episodes decrease roughly by 50%

22. Obesity
 Increase risk of stone episodes
 Metabolic syndrome and stone disease: potential
correlation
 Dietary calcium restriction actually increases stone
recurrence risk.

23. Evaluation of conservative
management
 Re-evaluation after 3-4 months
 If metabolic or environmental abnormalities have
been corrected:
 Continue treatment and the patient
 Follow up every 6 to 12 months with repeat 24-hour
urine testing.

24.  If, however, a metabolic defect persists, a more
selective medical therapy may be instituted

25. Selective medical therapy

26. Surgical management
 Symptomatic renal stones in patients without any
other etiology of pain

27. Minimally invasive surgeries
 Percutaneous nephrolithotomy (PNL)
 Extracorporeal shock wave lithotripsy (ESWL)
 Retrograde intrarenal surgery (RIRS)
 Laparoscopic and robotic stone surgery

28. Open surgical management
1. Nephrolithotomy
2. Pyelolithotomy
3. Extended pyelolithotomy

29. PRE OPERATIVE EVALUATION

30. Pre-procedural antimicrobials
 Bacteriologic evaluation of the urine is mandatory
for all patients
 Antimicrobial prophylaxis for all cases of
percutaneous renal surgery (Wolf et al, 2008).

31.  Antimicrobial coverage should include organisms
common to the urinary tract:
 Escherichia coli,
 Proteus sp.,
 Klebsiella sp.,
 Enterococcus sp.
 and the skin:
 Staphylococcus aureus,
 coagulase-negative Staphylococcus sp.,
 group A Streptococcus sp.)

32. Percutaneous nephrolithotomy
 Indications:
1. Stone size >2 cm in size
2. Staghorn stones
3. Hard stone not fragmented by ESWL
4. Urinary tract obstruction that need correction

33.  Complications:
 Acute and delayed hemorrhage
 Collecting system injury
 Visceral injury
 Pleural injury
 Metabolic and physiologic complications

34.  Post op fever and sepsis
 Neuromusculoskeletal complications
 Venous thromboembolism
 Tube dislodgement
 Collecting system obstruction
 Loss of renal function
 Death

35. POSTPROCEDURAL
NEPHROSTOMY DRAINAGE
Malecot’s catheter Balloon catheter

36. Cope catheter
Ureteral stent

37. Extracorporeal Shockwave Lithotripsy
 Most patients harboring “simple”
renal calculi can be treated
satisfactorily with SWL
 Outpatient procedure
 Indication
 stone size < 2 cm size

38.  Contraindications
 Pregnancy
 Large abdominal aortic aneurysm
 Uncorrectable bleeding disorder
 Body habitus
 Obstruction distal to the stone

39.  Complications:
 Fragments may become impacted in the ureter
 Hematuria
 Renal hematoma
 Infection
 Kidney damage

40. Retrograde Intrarenal Surgery
(RIRS)

41.  Indications:
 Failed ESWL
 RIRS assisted ESWL
 Radiolucent stones
 Calyceal diverticular stone

42.  Used in patients with ESWL contra-indications:
 Bleeding disorder or anticoagulant
 Obesity
 Pregnancy

43.  Complications:
 Sepsis
 Steinstrasse
 Stricture
 Ureteric injury
 UTI

44. Anatrophic nephrolithotomy
 Gold standard for staghorn calculi
 Removal of all calculi and open surgical correction of
the anatomical obstruction

45.  Complications:
 Pulmonary complications
 Post op renal hemorrhage
 Stone recurrences
 Urinary extravasation

46. Pyelolithotomy
 Effective, especially for extra renal pelvis
 For pelvic stone

49. COMPARATIVE STUDIES

50. SFR in different procedures:

53. Prevention of recurrence
 Normal balanced diet
 Milk products (calcium stones)
 Strawberries, plums, spinach and asparagus (calcium
oxalate stones)
 Uric acid stone patient should avoid red meats, and fish
 Cystine stone patient should be restricted Eggs, meat
and fish are high in sulphur

54. Conclusion
 The diagnosis of nephrolithiasis is often made on the
basis of clinical symptoms alone, although
confirmatory tests are usually performed.
 Medical treatment of nephrolithiasis involves
supportive care and removal of risk factors
 Stones that are 7 mm and larger are unlikely to pass
spontaneously and require some type of surgical
procedure

55. References

56. THANK YOU !!!