Renal/Kidney stone/calculus, types, causes, management.

2. Dr. Prajyoth Reddy
Chief Resident
Dept of General Surgery
Bharati Vidyapeeth Hospital & Research
Centre, Pune

3.  Most common disease of the urinary tract.
 12% Worldwide Incidence.
 12% Indian Population.
1.5 Indian
3 African
1.2 American
2 European
4.3 rest of the world
-Alelign, T., & Petros, B. (2018). Kidney
Stone Disease: An Update on Current
Concepts. Advances in urology, 2018,
3068365. doi:10.1155/2018/3068365

4. Stone Belt

5. Most patients tend to present between 30-60years of age.
Male :Female (3:1)
More common inAsians and whites than in Native
Mediterranean Americans, Africans, AfricanAmericans.
Geography (stonesare more common in hot and dry areas).
Diet and Hereditary also appears to be factor.

6. 1. Diet – Vitamin A deficiency causes desquamation of epithelium
which acts as a nidus for stone formation.
2. Climate – In hot climate, urinary solutes will increase with decrease in
colloids, which leads to chelation of solutes with calcium forming a
nidus for stone.
3. Citrate level in urine (300-900 mg/24 hours) maintains the calcium
phosphate and carbonate in soluble state. So any decrease in citrate
level in urine causes stone formation.
4. Infection – Urea splitting organisms (E.coli, Staphylococcus, Proteus)

7. 5. Prolonged Immobilization- Causes skeletal decalcification resulting in
increase in urinary calcium favoring stone formation.
6. Inadequate urinary drainage and urinary stasis (eg. Ureteral stricture)
7. Metabolic-
Hyperparathyroidism  hypercalciuria  B/L Nephrocalcinosis
Altered glycine metabolism  Hyperoxaluria  Oxalate stones
Hyperuricosuria (Gout)  Uric acid stones
8. Drugs like acetazolamide, indinavir, ephedrine and triamterene are
associated with urolithiasis

11.  The development of minimally invasive surgical techniques for stone
surgery has depended heavily on technologic advances in several areas,
including fiberoptics; imaging; and development of shock wave,
ultrasonic, electrohydraulic, and laser lithotriptors. Available
technology accelerated development of modern techniques for stone
removal including, ureteroscopic stone removal (URS), PNL, and most
importantly, ESWL. The term endourology was coined to encompass
antegrade and retrograde techniques for the closed manipulation of the
urinary tract.

12.  Surgical management is advised if the stone is
>20cm. Management depends on the location of
the stone.
 Management of stone depends on stone burden
(size and number), stone composition, and stone
location.

13. • The goal of surgical stone management is to achieve maximal stone
clearance with minimal morbidity to the patient.
• Four minimally invasive treatment modalities are available for the
treatment of kidney stones ESWL, PNL, retrograde ureteroscopic
intrarenal surgery (RIRS), and laparoscopic stone surgery.

14. Most of the Stones can be removed without open Sx by:
ESWL - Extracorporeal shock wave lithotripsy (ESWL). This uses high-
energy shock waves which are focused on to the stones from a machine outside
the body to break up stones. You then pass out the tiny broken fragments when
you pass urine.

15. Uses focused Shock Waves to
breakdown a stone into small pieces.
Shock waves are acoustic pulses.
Pass through better in water and solid
but not in air.
Introduced in 1980 by Dornier.

16. - Find out the location of stone
- Pre-medication (pain relief)
- Check LMP for female patients
- Brief the details of the treatment to the
patient
Preparation

17. Contra-indication
Relevant coagulation problems
Tumors in shock wave area
Aneurysms
Polyarthritis (difficult to positioning)
Active pyelonephritis
Pregnancy
• Stones of less than 2 cm in the kidney
Or
• less than 1 cm in the ureter.

18. 1) Compare with the previous KUBimage
2) Using, iliac crest and the spine aslandmark
3) Move the patient in the mid level of the removable broad
Procedure

19. 4) Remove the board
5) Apply gel to the coupling cushion
6) Move the coupling cushion to treatment position
7) Increase the coupling pressure and touch the patient
skin
8) Apply soft pad or sand bag on the opposite side
of the patient (immobilize the patient)

20. 10) Screening in PA view
11) Move the table to locate the stone in the center
12) Adjust the height of the table to locate the stone in center

21. 2
1
• The efficacy of PCNL was shown to be independent of stone size
(approximately 90% stone free rate), whereas the efficacy of ESWL dropped
rapidly as stone size increased (from 74% to 56% to 33% for stones 10 mm or
smaller, 11 to 20 mm, and larger than 20 mm, respectively).
• The results of the Lower Pole Study Group suggest that PCNL should be
considered the primary approach for LPS larger than 10 mm.

23.  Indications- Stones more than 2cm in size;
multiple stones; stones not responding to ESWL.
 Procedure- Initially cystoscopy is done and
ureteric stent/catheter is placed and renal PCS is
identified under C-arm guidance. Needle puncture
is made in the loin percutaenously. Through kidney,
calyx and pelvis are approached. Guide wire is
passed, Graduated dilators are passed and so the
track is widened. Then through that a nephroscope
is passed. Stone is fragmented and is removed.

24.  Other Indications-
- Anatomic abnormalities such as PUJ obstruction, calyceal diverticula or
ureteric obstruction.
- Obese patients in whom ESWL is contraindicated
- Lower calyceal stones which are less likely to pass after ESWL
- Hard stones (Calcium oxalate and cystine stones)
• Complications-
- Injury to spleen, pleura and colon
- Haemorrhage
- Sepsis
- Extravasation due to rupture of collecting system
- Retained stone fragments

25.  RIRS- Retrograde intrarenal surgery. i.e., endoscopic surgery for
management of stone within the renal collecting system using a
retrograde closed approach.

26.  Stones upto 1.5cm
 Lower calyceal stone
 Stone procimal to stricture
 Stones that cannot be positioned for ESWL (Obesity, radiolucent)
 Anticoagulated patients

27. 27
• Anatomic factors, congenital or acquired, that hinder stone clearance
adversely affect the results of ESWL.
• Ureteropelvic Junction Obstruction: Although, patients with stones
and concomitant ureteropelvic junction obstruction have traditionally
been treated by open pyeloplasty and stone extraction, PCNL with
concomitant endopyelotomy can achieve good results with less morbidity.

28. Horseshoe kidney & Renal Ectopia:-
ESWL can achieve satisfactory results in properly selected patients (i.e., those
with stones less than 1.5 cm) in the presence of normal urinary drainage.
For larger stones or when there is evidence of poor urinary drainage, PCNL
should be used as the primary approach.
• Ectopic Kidney : - Treatment of choice ESWL Alternatively, percutaneous
transperitoneal nephrolithotomy can be done.
• Lower Pole Stones: - Overall stone-free rate for ESWL when applied to LPS
was 60%. In comparison, the results of ESWL for upper and middle pole
calyces range from 70% to 90%.

29. • Morbid obesity: - RIRS may be the preferred treatment for morbidly obese
patients when the stone burden is not excessively large.
• Patients with spinal deformity or limb contractures may also be difficult to
position within the lithotriptor. Alternative treatment modalities, including
PCNL and ureteroscopy using flexible instruments, may be preferable in
these patients.

30.  Staghorn calculi refer to
branched stones that fill all or part
of the renal pelvis and branch into
several or all of the calyces. They
are most often composed of
struvite (magnesium ammonium
phosphate) and/or calcium
carbonate apatite.

31. • The ideal management of staghorn calculi is
First, complete surgical removal of the entire stone burden is essential. If all the infected
material is not removed, urea-splitting bacteriuria may persist, leading to eventual stone
regrowth. The procedure or combination of procedures most likely to render the patient free
of stone material with the lowest morbidity should be selected.
Second, any metabolic abnormalities need to be identified and treated appropriately.

32. Surgical Management of Staghorn Calculi
• OPEN STONE SURGERY (OSS) : - Overall, the
stone-free rate after OSS for struvite stones is
about 85%.
32

33. • URETEROLITHOTOMY: - Long standing ureteral calculi
those inaccessible with endoscopy and those resistant to
ESWL can be extracted with this technique.
• COAGULUM PYELOLITHOTOMY: - Is mainly indicated in
cases of multiple stones, soft and crumbly stone or stones,
small, mobile caliceal stones, and as an aid to fixing
caliceal stone or stones in the calix prior to partial
resection of the kidney or nephrolithotomy.
33

34. 34
• SANDWICH THERAPY: - The most frequently used regimen
was described by Streem and coworkers (1987) as sandwich
therapy, consisting of primary percutaneous debulking
followed by ESWL of residual inaccessible infundibulo-
calyceal stone extensions or fragments. After ESWL, a
secondary percutaneous procedure is performed (Streem,
1997b).
• Nephrectomy: - This is a reasonable option for a poorly
functioning kidney bearing a staghorn stone.

35. Ureter has 3Constrictions:
1. Pelvic-ureteric junction
2. When it crosses external iliacvessel
3. Vesico-ureteric junction

36. 1. Always of Renal Origin
2. Commonly of elongated shape
3. Can get impacted at 3 constrictions
of ureter
4. Can cause:
Obstruction
Hydronephros
is Infection
Ureteral
Stricture

37. Ureteric Calculi Surgical Mx
• The goal of surgical management of ureteral calculi is to achieve
complete stone clearance with minimal morbidity to the patient.
• Most ureteral calculi that are <6mm pass spontaneously, although
not without discomfort and expense to the patient. Ureteral
calculi of any size are often associated with renal obstruction,
and care must be taken to prevent irreversible damage to the
kidney, whether choosing expectant or active treatment.

38. 53
65

39. FACTORS AFFECTING TREATMENT DECISIONS
1) Location: The statistical probability of spontaneous ureteral stone passage is
inversely related to stone size and proportional to the distance of the ureter
traversed.
2) Size and number: - stones less than 5 mm in diameter pass spontaneously.
Stones larger than 8 mm require ESWL or Ureterscopy removal.
39
3) Stone composition: - Brushite, cystine, and calcium oxalate monohydrate are
relatively resistant to ESWL.

40. • Treating patients with ureteral calculi can be grouped into five general
categories:
1) Observation (also termed “expectant management” and “watchful
waiting”);
2) Shock wave lithotripsy (SWL);
3) Ureteroscopic Lithotripsy (URS);
4) Percutaneous nephrolithotomy (PCNL); and
5) Open surgery (referring to any method of open
surgical exposure of the ureter and removal of stones)

41.  The surgical treatment options for proximal ureteral
stones include ESWL with or without stone
manipulation; ureteroscopy; PNL; and, rarely, open
and laparoscopic stone surgery.
 ESWL, by whatever technique (push back or in situ),
should be the primary approach for stones of less than
1 cm in the proximal ureter. For stones larger than 1
cm in diameter, ESWL, PNL, and ureteroscopy are all
acceptable choices.

42. • Surgical treatment options for distal ureteral
stones with or without a stent; ureteroscopy
with extraction or intracorporeal lithotripsy;
and, rarely, open and laparoscopic stone
surgery.
• ESWL and ureteroscopy were both
considered acceptable treatment options

43. • Although some ureteral stones can be treated with ESWL, urethroscopy may
be needed for mid & lower ureteric stones. No incision is made in the
procedure, Instead, the surgeon passes a small fiberoptic instrument called a
ureteroscope through the urethra and bladder into the ureter.
• The surgeon then locates the stone and either removes it with a cage-like
device or shatters it with a special instrument that produces a form of
shockwave. A small tube or stent may be left in the ureter for a few days after
treatment to help the lining of the ureter heal.

45. 1. Primary vesicalcalculus:
- Rare
- Develops in sterile urine
- Often originates in kidney
2. Secondary vesicalcalculus:
- Occurs inpresence of infection ,outflowobstruction,
impairedbladderemptyingoraforeignbody
- UsuallyUric acid or calcium oxalate.

46. Same as that of Renal Calculus
Others:
1. Diverticula bladder
2. BPH
3. Urethral Stricture
4. Neurogenic Bladder
5. Schistosomiasis

50. Frequency more during day than night, because during day, due to
ambulation stone comes in contact with trigone of the bladder and
irritates.
Pain –referredto tipof penis or labia.
Burning micturition andfever.

53. • General/Indications - With the advent of ESWL and PCNL
techniques, open surgical procedures on the kidney have been
made virtually obsolete. There are, however, specific indications
warranting open surgery. These include: failure of ESWL or
PCNL to fragment the entire stone
• Large stone burden that would require multiple ESWL and/or
PCNL procedures
• Certain anatomic abnormalities of the urinary tract.

54.  Posterior (Loin) – Most common
 Anterior
 Thoracoabdominal

55.  Suitable for stones in extrarenal pelvis. By loin incision, kidney is
approached. Renal pelvis is opened and stone is removed.
 Gil-Vernet procedure
 In case of intrarenal pelvis, incision is done on the hilum between the
pelvis and kidney over the renal sinus, dissection is carried out so as to
remove the stones from the pelvis as well as calyces.

56.  By placing the incision just behind the most convex surface (Brodel’s line), stone
is removed.
 By taking incisions both over the kidney and pelvis stone/stones are removed.
Often done in Staghorn calculus.
 Done when there are multiple stones occupying a pole, usually lower pole of the
kidney or when there is damage to calyx.

57.  Kidney is removed out temporarily, cooled by ice packs or inosine or liquid
nitrogen. Stones are searched and removed completely. Later kidney is replaced
in RIF.
 Coagulum solution which contains fibrinogen is poured into the renal pelvis.
Solidifies when activated, meanwhile entangling the stones in renal pelvis. This
entangled mass is removed en masse.
 After exposing the kidney, it is cooled with ice packs for 20min and posterior
branch of the renal artery is clamped temporarily, this manoever exposes the
Brodels line properly. Kidney is opened thru this line and stone is removed.

58.  SANDWICH THERAPY: - The most frequently used regimen was
described by Streem and coworkers (1987) as sandwich therapy,
consisting of primary percutaneous debulking followed by ESWL of
residual inaccessible infundibulo-calyceal stone extensions or fragments.
After ESWL, a secondary percutaneous procedure is performed (Streem,
1997b).

59.  Keep Hydrating yourself , thank you