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1. CALCULI InCALCULI In
UrInAry TrACTUrInAry TrACT
Sunil Kumar Daha

3. AetiologyAetiology
Diet-Vit-A deficiency- desquamation of epithelium
Altered urinary solutes and colloids
-dehydration
-adsorbs solutes, mucoproteins– chelate calcium
Decreased urinary citrate (300-900 mg/24hr)
-Insoluble calcium phosphate
Renal infection
Inadequate urinary drainage and stasis
Prolonged immobilization
Hyperparathyroidism

4. Renal Calculi :TypesRenal Calculi :Types
1) Oxalate calculus (calcium oxalate)
- Irregular in shape and covered with sharp projections- bleedings
-Hard and radio opaque ,common
2) Phosphate calculus
-Calcium phosphate often with ammonium magnesium phosphate (struvite)
- Large, smooth and dirty white, grow in alkaline urine
- Enlarge, a staghorn calculus, radio opaque
3) Uric acid and urate calculi
- Hard, smooth, round to oval and often multiple,
-Yellow to reddish brown
- Pure uric acid stones- radiolucent (filling defect on radiographs)

5. ……typestypes
4) Cystine calculus
- Congenital error of metabolism-- cystinuria
- Hexagonal, translucent, white crystals, appear only in acid
urine
- Multiple; pink or yellow when first removed, changes to
greenish when exposed to air
- Radio opaque(sulphur), and are very hard
5) Xanthine calculus
- Extremely rare
- Smooth and round, brick-red in colour
- Shows lamellation on cross-section

6. Clinical FeaturesClinical Features
30-50 yrs (50%)
Male: Female = 4:3
Silent calculus
Pain in the renal angle and hypochondrium
Severe exacerbation on a background of
continuing pain
Radiates to groin, penis, scrotum or labium
Pain severity not related to size of stones
Hematuria
Pyuria

7. InvestigationsInvestigations
Urine analysis  crystals
Radiography- KUB
USG
Intravenous Urography(IVU)
Contrast Enhanced Computerized
Tomography
Serum- calcium, uric acid
Analysis of any stone passed

8. ManagementManagement
Small stones (<0.5cm) pass without
surgery unless they are impacted
Antibiotics starts before surgery and
continues after surgery

9. Modern methods of stone removalModern methods of stone removal
Percutaneous nephrolithotomy
- Placement of a hollow needle into the renal
collecting system through the soft tissue of the loin
and renal parenchyma, grasped or fragmented
(larger)
Complications: hemorrhage, perforation of collecting
system with extravasation of saline irrigant,
perforation of colon or pleural cavity

10. ……modern methodsmodern methods
Extracorporeal shock wave lithotripsy
(ESWL)
- Bombarded with shock waves of sufficient energy,
disintegrates into fragments
- Fluid is confined to the path
Complications: ureteric colic after ESWL, chance of
infection after broken calculus
Open Surgery
- Pyelolithotomy
- Extended pyelolithotomy
- Nephrolithotomy

11. Management…Management…
Bilateral renal stones:
- Treat the better kidney first unless other kidney
is more painful or has pyonephrosis
Prevent recurrence:
- Rule out metabolic cause: Measure serum
calcium, uric acid
- Diet: Calcium : milk products
Ca Oxalate: Strawberries, Rhubarb,
spinach, asparagus
Urate: Red meat
Cystine: Eggs, meat, fish

12. Ureteric CalculusUreteric Calculus
C/F: intermittent attacks of ureteric colic
- Referred to groin, external genitalia, ant
surface of thigh
- Cremasteric spasm- testis retraction
- Stone in intramural ureter- pain at tip of
penis, painful, dribbling micturation
- Hematuria
- Distension of renal pelvis

13. ImpactionImpaction

14. TreatmentTreatment
Pain management- NSAIDs
Removal of the stone- Indication for surgery:-
- Repeated attacks, stone is not moving
- Enlarging stone
- Complete obstruction
- Urinary infection
- Too large stone to pass
- Bilateral or solitary kidney obstruction
….

15. Treatment…Treatment…
Endoscopic stone removal
◦ Dormia basket
◦ Ureteric meatotomy
Ureteroscopic stone removal
- Transurethrally across the bladder into the ureter
- Push bang
Lithotripsy in situ
Open surgery- ureterolithotomy

16. Bladder stonesBladder stones
Primary- develops in sterile urine, often
originates in kidney
Secondary- in presence of infection,
outflow obstruction, impaired bladder
emptying or foreign body
Gravitates to the lowest part
M:F= 8:1
May be asymptomatic

17. SymptomsSymptoms
• Frequency
• Sensation of incomplete bladder emptying
• Pain (strangury), at the end of micturation
• Pain worsened by movements
• Haematuria
• Interruption of urinary stream- stone
blocking the internal meatus
• Urinary infection

18. Examination and InvestigationsExamination and Investigations
A large calculus- palpable in female
Urine Ex: microscopic haematuria, pus or
crystals (envelop like- oxalate, hexagonal
plates- cystein calculi)
Radiograph
USG

19. TreatmentTreatment
Litholapaxy
- Optical lithotrite, electrohydraulic lithotrite, Holmium laser
or ultrasound probe, stone punch, Ellik evacuator
Contraindications:
 a urethral stricture that cannot be dilated sufficiently (pt<10
yrs),
 a contracted bladder,
 a very large stone
Percutaneous suprapubic litholapaxy

20. ReferencesReferences
Bailey & Love’s Short Practice of Surgery,
26th
Edition
SRB’s textbook of surgery, 5th
edition