This document discusses upper urinary tract calculi (kidney stones). It notes that kidney stones are common in Pakistan and are caused by many factors. The document describes the types of stones, risk factors like diet and climate, and the multi-step process of stone formation. It outlines evaluations for stones and treatments options ranging from conservative management to procedures like ESWL, ureteroscopy, and surgery depending on the stone size, location, and other factors.

1. Upper Urinary Tract Calculi Dr Ahmed Rehman FCPS (URO) Assistant Professes of urology

2. Learning Objectives To enumerates factors involved in stone formation and describe their role To describe clinical features of urolithiasis To name investigations to workup a case of calculus To describe different stages of disease To choose suitable treatment option for each stage of disease

3. Urolithiasis Urinary stones are pieces of solid matter formed in the urinary tract out of normal or abnormal urinary constituents. Calculi are polycrystalline aggregates composed of varying amounts of crystalloids and organic matrix.

4. Urolithiasis Commonest urological problem in Pakistan 3 rd most common problem in West after infections and prostate Ancient time \ under developed world common stone was bladder Now the trend has shifted to kidneys, thanks to urbanization and civilization Roughly 3 to 1O% people suffer with a roughly 5O % recurrence in 5 years Merits higher in Pakistan, than in the West, as a cause of ESRD

5. Upper Urinary Tract Calculi Etiology Complex and not exactly known Only1O to 15 % cases cause can be found Rest labeled idiopathic Is not a single disease entity, end result of many known \ unknown factors Has been called a MULTI SYSTEMIC disease rather than a mere urinary problem Diseases of other systems set environment ripe for pathological uncontrolled biomineralization( stone formation, which in that case is a manifestation or complication of that disease. A disease or a symptom of diseases a big Q

6. Stones Types Calcarious calculi 8O% Calcium oxalate Non calcarious calculi Uric acid 5 to !O% Cystine <2% Xanthine Phosphate ammonium magnesium phosphate 5 to 1O% Mix calculi Matrix calculi Indinavir, silicate, triamterene

7. Etiological factors Heredity Age & sex effect Dietary factors Climatic & seasonal factors Geography Water intake Occupation Social class Obstruction \ stasis congenital and acquired Infections Altered urinary solutes and colloids Dehydration Increase conc of promoters or decrease conc of inhibitors Metabolic disorders Hyperparathyroidism Prolonged immobilization

8. Heredity Renal tubular acidosis, cystinuria xanthinuria Age Peak age 2O to 4O Extreme ages association with obstruction Sex More common in males 3 to 1

9. Climatic & seasonal factors Dry hot plains\deserts and cold high altitudes = perspiration, water intake Sunlight exposure vitamin D activation Geography Well defined stone belts environmental factors Water intake Low intake as opposite to perspiration, losses, requirement Mineral content zinc \ very hard and very soft water Occupation Sedentary , managerial professionals Affluent Social class animal protein p

10. Dietary factors High protein diet High Salt content Low water intake High calcium, oxalate and phosphate diet Low dietary citrate Vitamin A deficiency bladder calculi Fluid intake

11. Steps of stone formation Precipitation \ crystallization Saturation, Super saturation renal papilla Nucleation Homogeneous & heterogeneous Free & Fixed particle nucleation Crystal retention, Crystal growth and aggregation concretions, microliths Role of matrix nidus, glue, inhibitor, bystander Inhibitors & promoters of crystallization. metastable

12. Theories of stone formation Crystallization Precipitation theory Nucleation theory Crystal inhibition theory Fix particle theory Randalls plaque renal papilla Carr microliths lymphatics Theory of mass precipitation \ intranephronic precipitation Matrix nucleation theory

13. Calcium calculi etiology Hypercalciuria Absorptive Resorptive Hyperparathyroidism Renal induced Idiopathic Hyperuricosuria Hyperoxaluria Chronic diarrhea Enteric Primary Hypocitraturia p

14. Hypercalcemic nehrolithiasis Primary hyperthyroidism Malignancy associated hypercalcemia Granulomatosis \ sarcoidosis Hyperthyroidism Glucocorticoid induced hypercalcemia Pheochromocytoma Immobilization

15. Hypomagnesuria Renal tubular acidosis and calcium phosphate stones Gout and uric acid stones Inborn errors of metabolism

16. Ureteri calculi Origion Nearly always take birth in kidney Exceptions Stones in ureterocele Stones in kinked / dilated ureters Stones in strictured / stenosed ureters Stones in ureteric diverticulae Stones in schistosomiasis affected ureters Encrustations on foreign bodies Stents sutures

17. Clinical Features No symptoms Pain Renal pain renal angle > upper abdomen, Ureteric colic Acute, agonizing pain Rolls around as excruciating sharp pain supperimposed uppon a background of continous discomfort (peristalsis pushing stone down). Upper ureter = similar to renal colic Lower down = loin to groin, genitalia, anterior aspect of thigh, retracted tender testis Intramuural = ref to tip of penis, strangury (strong urge associated with failure to void except a few drops of blood stained urine) Dull (renal) ache due to hydronephrosis Consistant dull pain of impected stone, relieved by rest Pyuria, Haematuria Microscopic\ gross Fever, abscesses Infection Nausea & vomiting Acute renal failure \ anuria chronic renal failure Silent loss of kidney Squamous cell carcinoma of renal pelvis Perforations with fistula formation external, enteric

19. Clinical Examination No significant sign Some tenderness and rigidity over renal angle or some part of course of ureter Distress, Tachycardia, Fever, hypotension sweating Palpable kidney

20. Differential diagnosis Skin / subcutaneous tissues ---- Herpes Muscles – spasm, psoss abscess Bones – caries spine, psuedo renal (Radicular ) pain Lungs - Puemonia, plurecy,effusion Liver – hepatitis, abscess, GB – cholecystitis Appendicitis, typhlitis, large bowl obsruction Salpingitis, ectopic pregnency Ovarion cyst / tortion PID Splenomegaly Hydrnephrosis / renal mass, pyelonephritis Adrenals diseass Mural / extramural ureteric obstruction APD / Inferior wall MI Testicular pain, varicocele malingering

21. Complications Pyonephrosis Anuria Abscess Erosion and extravasation of urine Urinary fistulae formaation Loss of kidney / CRF Septicemia Cancer

22. Sites of impaction of ureteric calculi PUJ Iliac artery crossing Juxtaposition to vas or broad ligament Entrance into bladder Ureteric orifice

24. Investigations Baseline RFTs USG – hydro ureteronephrosis / stone X-ray KUB ROS false negative – small stone, obscured by gases, bones IVU/ delayed films Spiral CT Retrograde urography Renal scan

25. Emergency Treatment Pain relief Control of Infection Control of vomiting Hydration status

26. Treatment of renal calculi No treatment <4mm Conservative treatment < 5 to 8mm Noninvasive treatment ESWL \ stenting Conventional treatment Pyelolithotomy, Extended pyelolithotomy Nephrolithotomy Nephrectomy Minimal invasive treatment PCNL Sandwich therapy PCNL >ESWL >PCNL RIRS \ URS Laparoscopic pyelolithotomy

27. Treatment of ureteric calculi Expectant \ conservative Definitive therapy Noninvasive Minimally invasive Invasive

28. Expectant treatment Relief of pain Roll of NSAIDS Roll of sposmolytics Roll of IV fluids Roll of diuretic Roll of steroids Roll of edema reducing agens Roll of rest / exercise Roll of urinary alkalization Roll of antibiotics Roll of chemotherapy Roll of homeo therapy / indegenous medicine assessment of renal function & back pressure Follow up -- 4-6 weeks

29. Indications to abandon conservative therapy No progress Intractable pain Stone enlarging / too large a stone Fever (UTI) Oligurea / anurea / Renal function deterioration complete obstruction Bilateral Unilateral – solitary kidney Profession

30. Spontaneous passage Size 1-2mm ---- pass eventually 4-5 mm --- 40-50% >6mm ---- <5% Site shape Degree of hydronephrosis / impection Obstructive lesion

31. Definitive treatment Noninvasive ESWL in situ (with out push back) Upper ureter – suppine Lower and mid --- prone Countraindication : impected stone Infected system ( stenting or PCN followed by definative treatment ) Distal obstruction

33. Definitive treatment minimally invasive Endoscopic removal Dormia basket ============NOT USED NOW Ureteric metotomy- transurethral ureterolithotomy Uretro renoscopy Mechanical Intrcorporeal lithotripsy LASER Pnuematic lithoclast Ultrasound ellectrohydrolic Push bang stent \ ESWL Percutaneous techneque Perc and pull Push and perc Laproscopic ureterlithotomy Peritoneal Extraperitoneal

45. Definitive treatment invasive Uretrolithotomy Upper -------- flank subcostal incision Mid -------- gibson, grid iron, alaxander Lower ------- pfennesteil, hemi-pfennesteil, midline Transvesical ureterolithotomy Transvaginal ureterolithotomy Stenting Nephrectomy

56. BLADDER STONE Primary Secondary Incidence Child hood, Old age Types Oxalate, uric acids, phosphate Cystine

57. Symptoms Frequency Pain – stanguary Haematuria Interruption of stream UTI Investigations USG X-ray KUB & IVU Cystoscopy Page No. 6

58. TreatmentmechanicalMechanico hydraulic Litholapexy Contraindications to litholapexy Urethral stricture Very big stone Age below 10 years Contracted bladder Very hard stone Vesicolithotomy ESWL