Guide to Lower Urinary Tract Calculi

LOWER URINARY TRACT CALCULI
Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai 1
DEPT OF UROLOGY,GRH ANDKMC,CHENNAI.

MODERATORS:
Professors:
Prof. Dr. G. Sivasankar, M.S., M.Ch.,
Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
Dr. J. Sivabalan, M.S., M.Ch.,
Dr. R. Bhargavi, M.S., M.Ch.,
Dr. S. Raju, M.S., M.Ch.,
Dr. K. Muthurathinam, M.S., M.Ch.,
Dr. D. Tamilselvan, M.S., M.Ch.,
Dr. K. Senthilkumar, M.S., M.Ch.
DEPT OF UROLOGY,GRH ANDKMC,CHENNAI. 2

3

ORIGINAL 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.’
4

THE SPECIALIST
Aulus Cornelius Celsus 25 BC De Medicinia
5

AMMONIUS @ LITHOTOMOS, 200 BC
6

THE LITHOTOMY POSITION
7

THE LITHOTOMY POSITION
8

CELSIAN METHOD OR THE LESSER OPERATION
9

APPARATUS MINOR
10

MARIAN OPERATION
Marianus Sanctus Barolitanus 1558
11

APPARATUS MAJOR
12

THE 200 YEAR SECRET
Vs
13

TRAITÈ DE LA
LITHOTOMIE
1708
In1556, France.
Laurent Colot was
appointed court
lithotomist by Henry II.
François Colot died in
1706.
François Tolet (1647-
1724) was appointed
court lithotomist.
14

THE LATERAL OPERATION
Frère Jacques Beaulieu 1651–1720 Anatomy of lateral operation
15

THE LATERAL OPERATION
16

THE HIGH OPERATION 1719
James Douglas John Douglas
17

THE HIGH OPERATION 1723
William Cheselden The Treatise
18

THE HIGH OPERATION OF THE STONE 1723
19

GENERAL CLAUDE MARTIN OF LUCKNOW
1782
Breaking his own bladder stone using
an urethral sound
20

DEPUYTREN’S DOUBLE BISTOURY
21

DEPUYTREN’S DOUBLE BISTOURY
22

CIVIALE LITHOTRIPTER 1825
23

24

25

HEURTELOUP'S PERCUSSION LITHOTRITE 1840
26

HEURTELOUP'S PERCUSSION LITHOTRITE 1840
27

28

LOWER URINARY TRACT CALCULI
1. Bladder calculi
2. Prostatic calculi
3. Urethral calculi
4. Preputial calculi
29

BLADDER CALCULI
30

EPIDEMIOLOGY
Most common lower urinary tract lithiasis
5% of stone disease
31

TYPES
1. Primary bladder calculi
2. Secondary bladder calculi
32

PRIMARY BLADDER CALCULI
Stones develop in the absence of any known functional, anatomic or infectious factors.
It does not imply that stones have formed de novo in the bladder.
Common in stone belt regions associated with childhood bladder lithiasis.
33

STONE BELT REGIONS
34

PRIMARY BLADDER CALCULI-CHILDREN
More common in children younger than 10 yrs.
Peak incidence at 2-4 yrs of age
More common in boys than girls (9:1 to 33:1)
Usually solitary
Recurrence rare after removal
Common components:
Ammonium urate, Calcium oxalate and Calcium phosphate
35

PATHOGENESIS
1. Low protein and low phosphate diet
2. Oxalate rich diet
3. Low Vit B1, B6 and Magnesium intake
4. Vitamin A deficiency
5. Diarrhoea
36

LOW
PHOSPHATE
DIET
37

HIGH OXALATE
DIET
38

VITAMIN B6
DEFICIENCY
39

VITAMIN A
DEFICIENCY
40

SUBSTANDARD
LIVING
CONDITION
41

CLINICAL PRESENTATION
Acute presentation – Rare
Vague abdominal discomfort
Dysuria
Frequency
Hematuria
Pulling of penis (Strangury)
Rectal prolapse and conjunctival hemorrhages (Rare)
42

SECONDARY BLADDER CALCULI
Men older than 60
Associated with lower urinary tract obstruction
Urinary stasis leads to increased stone formation
May arise denovo in the bladder or
May result of migration of stone nidi from upper tracts and maturation in bladder.
43

SEC BLADDER CALCULI-ASSOCIATED CONDITIONS
1. Bladder outlet obstruction and acquired lower urinary tract pathologies
2. Intravesical foreign body
3. Neurogenic bladder and spinal cord injury
4. Transplant patients
44

BOO AND ACQUIRED LUT PATHOLOGIES
1. BPH
2. Cystocele and ureteral kinking
3. Urethral stricture
4. Bladder neck contracture
5. Bladder diverticula
45

BOO AND
ACQUIRED
PATHOLOGIES
46

INTRAVESICAL FOREIGN BODY
1. Mid urethral slings
2. Cerclage wires
3. Migrated IUDs, pessaries,
contraceptive diaphragms.
4. Retropubic prostatectomy dorsal
venous complex suture material
5. BPH chemical ablation necrotic tissue
6. Intraprostatic stents
7. Prostate brachytherapy seeds
8. Inflatable penile prosthesis erosion
9. Artificial urinary sphincter erosion and
encrustation
10. Chronic indwelling catheter
11. Clean Intermittent catheterization
(Hair nidus)
12. Migrated non genitourinary foreign
bodies (Orthopedic cement, surgical
clips, gall stones from cholecystectomy
spillage etc)
47

FOREIGN BODY
48

NEUROGENIC BLADDER AND SPINAL CORD INJURY
Spinal cord injury - Peak risk at 3 months
Recurrence is very common
Clean intermittent catheterization is better than chronic indwelling catheters
Suprapubic catheters no better than urethral catheters in terms of stone formation.
In children:
Incidence lower than adults.
Catheterisation through a Mitrofanoff conduit – Slightly higher incidence.
49

TRANSPLANT PATIENTS
Common in patients with combined pancreatic allograft transplantation. (0.5-10%)
Non absorbable suture material or surgical clips act as the nidus.
Potentiated By:
1. Bicarbonate leak
2. Urinary stasis and incomplete bladder emptying
3. Diabetic uropathy
4. Increased bacterial colonization of included duodenal segments
5. Immunosuppression
50

TRANSPLANT PATIENTS
Without pancreatic transplantation:
0-5% incidence
Most cases suture material used for anastomoses act as the nidus.
51

CLINICAL PRESENTATION
Macroscopic hematuria, usually terminal – most common
Intermittency,
Frequency,
Urgency,
Dysuria,
Decreased force of urinary stream,
Incontinence (Detrusor overactivity in larger stones >4cm),
Lower abdominal pain aggravated by brisk movements.
52

DIAGNOSIS - EAU 2019
USG of bladder - Sensitivity 20-83% and Specificity 98-100%
In adults, CT and/or cystoscopy are the optimum diagnostic investigations for
detection of bladder stones.
Plain X-ray KUB has a reported overall detection rate for cystoscopically verified
bladder stones of 21 to 78%.
Stones with a largest diameter measurement > 2.0 cm are detected in over half of
cases, as are stones with a total volume > 1.0 cm3
53

XRAY
MULTIPLE
LAMELLATED
STONES IN
NEUROGENIC
BLADDER
54

XRAY KUB
LARGE VESICAL
CALCULUS
55

CYSTOSCOPY
SPICULATED
JACK STONE
56

JACK STONES
Resembles the children play toy ‘Jacks’
Almost always composed of calcium oxalate dehydrate
Consists of a dense central core and radiating spicules.
Usually light brown with dark patches.
Susceptible to lithotripsy.
57

JACK STONES
58

CONSERVATIVE MANAGEMENT
Asymptomatic migratory bladder stones in adults may be left untreated, especially if
stones are small.
Stones < 1 cm are likely to pass in patients without urinary stasis, infection or foreign
body.
Primary and secondary bladder stones are usually symptomatic, they are unlikely to
pass spontaneously; thus, active treatment of such stones is usually indicated.
59

MULBERRY STONE
Subset of Jack stones with less well developed spikes.
Have mamillated appearance.
Made up of Calcium Oxalate dehydrate.
Easily breakable using lithotripsy.
60

MULBERRY STONE
61

NON OPERATIVE MANAGEMENT
Chemical dissolution is rarely considered as primary treatment.
When administered properly, Renacidin may be used to dissolve struvite and calcium
phosphate calculi. Contraindicated in renal insufficiency.
Oral potassium citrate or intravesical administration of alkaline solution can be used
for uric acid stones.
Chronic indwelling catheters – Acetohydroxamic acid irrigation reduces the incidence
of catheter encrustation.
62

OPEN CYSTOLITHOTOMY
Previously considered gold standard.
Now fallen into disfavor.
Reasons:
1. Need for prolonged catheterization
2. Wound infection
3. Increased postoperative morbidity
63

TRANSURETHRAL APPROACH
Allows natural orifice for approach.
Lithotrite generally disfavored due to associated mucosal injury and bladder
perforation.
Lithotripters using holmium, electrohydraulic and lithoclast technology are preferred.
Electrohydraulic lithotripsy - Associated with mucosal injury and hematuria
Holmium laser lithotripsy – Able to treat large calculi with minimum collateral
damage.
64

SHOCK WAVE LITHOTRIPSY
ESWL has been successfully used.
Patient is placed in prone position to eliminate obfuscation of pelvis and sacral spine.
Foley catheter is used for filling the bladder.
Per session 1000 to 4800 shocks are given.
Large stone fragments may require cystoscopic evacuation.
Retreatment required in 10-25% of patients.
Success rate 93-100%.
65

PERCUTANEOUS CYSTOLITHOTRIPSY
Useful in patients without urethral access like in Bladder neck reconstruction or closure.
Dilatation and creation of suprapubic tract after bladder distension.
After breaking the stone using ultrasonic or pneumatic energy, fragments are
removed.
66

AUGMENTED BLADDERS AND
URINARY DIVERSION
67

BLADDER AUGMENTATION
Incidence 10-52.5%
Females more commonly affected.
Mean time to stone formation 24.5 to 60 months.
Risk of recurrence 19-44%
Struvite stones more common.
Calcium phosphate stones also common due to high pH.
Uric acid stones are rare.
68

BLADDER AUGMENTATION-PATHOGENESIS
1. Bacteriuria and UTI
2. Associated procedures like bladder neck reconstruction, artificial urinary sphincter
placement, urethral sling procedures leading to urinary stasis.
3. Catheterisation through non dependent access like Mitrafanoff access.
4. Dehydration, hypocitraturia and high urinary pH.
5. Intestinal mucus acting as nidus ??? (Gastrocystoplasty – Least stone formation)
69

URINARY DIVERSION
Incidence depends on the type of diversion created.
More common with continent diversions.
Stomal stenosis in incontinent diversions can lead to stone formation.
Among continent diversions, lndiana pouch and orthotopic neobladder associated
with low incidence.
Incidence very high upto 50% in Koch’s pouch. (Exposed staple lines and non
absorbable mesh collar)
Struvite and calcium phosphate stones more common.
70

TREATMENT
Conduit diversions – Looposcopy with lithotripsy
Stomal stenosis - Revision of Stoma
Orthotopic diversions and augmented bladders – Transurethral approach
Bladder neck reconstruction or anti-incontinence procedures – Use instrument only
upto 21 Fr to prevent disruption.
Mitrofanoff - Endoscopic management through the conduit not advised.
Indiana pouch – Trans stomal endoscopic management not recommended.
Percutaneous approach is suitable.
Koch’s pouch – Trans stomal endoscopic management can be done.
71

URETHRAL CALCULI
72

URETHRAL CALCULI
Least common manifestation of lower urinary tract lithiasis.
0.3% of all urinary stone disease in endemic regions.
Bimodal age distribution – Peak incidence in early childhood and in fourth decade of
life.
73

URETHRAL CALCULI
Types:
1. Migratory calculi
2. Primary urethral calculi
74

MIGRATORY CALCULI
BPH, urethral stricture or meatal stenosis often present, inhibiting the ability to clear
migratory calculi.
Calcium oxalate present in 86-100% of cases.
(Migration from Upper tract > Bladder)
75

PRIMARY URETHRAL CALCULI
Arise denovo in the urethra
Through condensation of stone material on urethral foreign bodies or from stasis of
urine in urethral diverticula.
Struvite stones predominate.
Calcium phosphate and uric acid stones also noted.
Concomitant UTI with E.coli, Proteus or enterococci often present.
76

PRIMARY URETHRAL CALCULI - NIDUS
1. Hair bearing urethroplasty grafts
2. Suture material for urethral construction
3. Devitalised or necrotic tissue from TURP
4. Radioactive seeds used for prostate brachytherapy
5. Self mutilation and associated foreign body in urethra.
77

CALCULI IN URETHRAL DIVERTICULA
May be primary urethral calculi or migratory calculi.
In female ureteric calculi, urethral diverticulum nearly present in all cases.
Variable stone composition.
78

PRESENTATION
Depends on pathogenesis and location of the stone in the urethra.
Migratory calculi:
Acute LUT symptoms from stone impaction – Strangury, urinary retention, gross
hematuria, dysuria.
Primary urethral calculi and Diverticular calculi:
More insidious symptoms
79

DIAGNOSIS
98-100% of urethral calculi are radiopaque in plain radiographs.
Prostatic calculi easily visualized in TRUS.
Urethrography or cross sectional imaging may aid in the diagnosis.
80

PLAIN XRAY
81

TRUS
PROSTATIC
CALCULUS
82

TREATMENT
Determined by location and associated anomalies.
Stones in Posterior urethra:
Push back into bladder and fragmentation or ESWL
Stones in Anterior urethra:
Retrograde relocatioin rarely feasible.
If smooth stone, milking the stone may be successful.
In case of irregular stone, may cause urethral injury.
Not amenable for simple manipulation: Urethrotomy and stone extraction.
83

TREATEMENT – INSITU LITHOTRIPSY??
May be feasible with success rate of 83%
Holmium laser has excellent efficacy.
Electrohydraulic lithotripsy and Swiss lithoclast associated with collateral urethral
damage.
84

STONES IN DIVERTICULA - RX
Incision of diverticulum and stone extraction.
Diverticulectomy and urethral repair may be performed concurrently or in a staged
fashion.
85

PROSTATIC CALCULI
86

PROSTATIC CALCULI
Overwhelmingly common
99% of asymptomatic men noted to have some degree of calcification.
Believed to be due to result of inspissation of prostatic secretions with in the prostatic
ducts.
93% present in posterior and posterolateral zones of prostate.
Made of Calcium phosphate and Calcium carbonate
Typically asymptomatic
If exceptionally large, can cause urinary tract obstruction
87

EVALUATION
Few patients ever require specific evaluation
Imaging performed for other indications may show prostatic calcification.
On plain film, 14% of prostatic calcifications are noted.
TRUS is highly sensitive for large prostatic calculi.
88

XRAY
PROSTATIC
CALCIFICATION
89

TRUS
PROSTATIC
CALCIFICATION
90

MANAGEMENT
For rare patients, who experience significant morbidity from prostatic calculi, removal
of the affected tissue may be attempted.
Surgical procedures include:
Open prostatolithotomy,
TURP,
Fragmentation with holmium laser lithotripsy.
91

PREPUCIAL CALCULI
92

PREPUCIAL CALCULI
Only handful of cases reported.
May occur at any age, more common among adults and the elderly.
Associated with severe phimosis in uncircumcised males.
Additional risk factors: Poor hygiene and low socioeconomic status
93

PATHOGENESIS
 Inspissated smegma,
Stasis with precipitation of urinary salts or
A combination of the two (Smegma acting as a nidus for urinary salts deposition.)
 Smegma irritates the prepuce causing scarring and phimosis leading to urinary
stasis.
Prepuce acts as an expansile urinary reservoir leading to stasis.
Foreign body such as suture material
Trapping of voided bladder calculi in patients with severe phimosis
94

PRESENTATION
Progressive voiding difficulty
Ballooning of prepuce with voiding
Palpable calculi in the preputial sac
Foul smelling discharge
Bilateral inguinal lymphadenopathy (if present suspect carcinoma)
95

PREPUTIAL CALCULI
96

TREATMENT
Circumcision or Dorsal slit procedure and removal of the calculi
Foreign objects if present should be removed entirely if present
Excised should be sent for HPE
97

THANK YOU
98

Guide to Lower Urinary Tract Calculi

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Guide to Lower Urinary Tract Calculi

Similar to Guide to Lower Urinary Tract Calculi (20)

More from GovtRoyapettahHospit

More from GovtRoyapettahHospit (20)

Recently uploaded

Recently uploaded (20)

Guide to Lower Urinary Tract Calculi