This topic is very important for MBBS - Students....as they are one of the common causes of Acute Abdomen. The students should know the types of renal calculus and their presentation in patients. Also, when to go for conservative treatment and when to surgically intervene....They should also know the preventive measures against stone formation....

1. Prof. U. Murali.
Urolithiasis

2. Learning Objectives
 Identify the D / D of Renal colic.
 List out the types of Renal calculus.
 Describe the etiology, C/F, investigations & treatment of
Renal, Ureteric & Vesical calculus.
 Explain the pathophysiology of stone formation.
 Discuss about Stag-horn calculus.

3. Introduction
 The lifetime prevalence varies from 1% to
20% and the causes are multifactorial.
 Recurrence of stone disease is high, with
50% having recurrence within the first
decade of diagnosis.
 Bladder stones account for 5% of all
urinary tract stone disease.
 The modern world is witnessing a steady
increase in the incidence of renal calculi.

4. Renal Colic
The commonest urologic emergency.
One of the commonest causes of the
“Acute Abdomen”.
Sudden onset of severe pain in the
flank.
Most often due to the passage of a
stone formed in the kidney, down
through the ureter.

5. Renal Colic
 When caused by acute obstruction of the
renal pelvis, is typically fixed deep in the loin
and ‘bursting’ in character.
 When caused by acute ureteric obstruction
(usually by a stone), is colicky with sharp
exacerbations against a constant back -
ground.
 Is liable to be referred to the groin, scrotum or
labium as the calculus obstruction moves
distally.

6. Renal Colic – D / D
 Pyelonephritis
 Abdominal aortic aneurysm
 Appendicitis
 Biliary colic (gallstones)
 Peritonitis
 Diverticulitis
 Salpingitis
 Torsion - ovarian cyst
 Ectopic pregnancy
 Shingles

8. Prof. U. Murali.
Renal Calculus

9. Renal Calculus – Etiology
 Diet: Vitamin A deficiency — desquamation of epithelium - acts as a
nidus – for stone formation.
 Climate: In hot climate Urinary solutes will ↑ with ↓ in colloids, which →
chelation of solute with calcium forming a nidus for stone.
 Any ↓ Citrate level in urine causes stone formation.
 Infection in kidney: Organisms - i.e. E. coli, Staphylococcus,
Streptococcus, Proteus.
 Prolonged immobilisation - decalcification of bones - leading to stone
formation.
 Stasis due to obstruction to urine flow.
 Hyperparathyroidism - causes hypercalcaemia / hypercalciuria →
causing multiple stones.
 Randall’s plaque theory – Deposition of urinary salts as plaque – at the
apex of renal papillae.

11. Renal Calculus – Stages in Stone form.
 Super-saturation
 Nucleus formation
 Crystallisation
 Aggregation
 Matrix formation
 Stone

13. Renal Calculus – Types
 Oxalate stones: 60-85%
Invariably Ca. oxalate / Irregular with
sharp projections. (mulberry stone)
Phosphate stones: 10 -15%
It is made of calcium, magnesium &
ammonium phosphate, usually
occurring in an infected urine. It
enlarges rapidly, filling renal calyces -
staghorn calculus.

14. Renal Calculus – Types
 Uric acid stones: are smooth,
multiple, multifaceted and
radiolucent.
Cystine stones: occur in cystinuria.
Often multiple and very hard, occurs
only in acidic urine.
Others -
Urate stones / Xanthine stones /
Indigo stones / Struvite stones.

16. Renal Calculus – Clinical Features
Pain — Fixed renal pain - over renal
angle, hypochondrium & lumbar region.
Vomiting due to pylorospasm. Pain
worsens on movements.
Haematuria is common.
Pyuria & Fever.
P/A - Tenderness in renal angle, with
often a mass in the loin due to
hydronephrosis.
 As urinary tract infection.
 Incidental finding – Silent calculus.

17. Renal Stones – Investigations
Blood tests
Urine - MSU & C/S
X-ray KUB
U/S – Abdomen
IVP
CT scan - NCCT

18. Renal Stones – Medical Treatment
Calculi < 0.5 cm - spontaneously
Pain relief - NSAIDs
IV – Fluids - Frusemide
Most calculi are treated by MIT
PCNL / ESWL / URS - RIRS

22. Renal stones – Surgical Treatment
Stones > 2.5 cm
in size
 Multiple stones
 Stones not
responding for
ESWL
Pyelo-lithotomy
Extended Pyelo-lithotomy
Nephro-pyelolithotomy
Nephrolithotomy
Partial nephrectomy
Coagulum pyelolithotomy
Laparoscopic
pyelolithotomy

23. Prof. U. Murali.
Ureteric Calculus

24. Ureteric Stones – Sites of Obstruction
 Always of renal origin.
 Nature of stones are same as
that of renal stones.
 They are commonly of
elongated shape.
 They can get impacted at
various narrow junctions.

25. Ureteric Calculus – C/F
Pain — It is of colicky type and
radiates from loin to groin often to the
tip of the genitalia - testis in males,
labia majora in females [G F N].
It is severe in intensity, increases with
exercise.
Nausea, vomiting, sweating due to
pain and reflex pylorospasm.
Haematuria, dysuria, frequency,
strangury.
Tenderness in over some part of the
course of the ureter - (iliac fossa /
renal angle).

26. Ureteric Stones – Investigations
Blood tests
Urine – MSU | C/S
X-ray KUB
U/S – Abdomen
IVP
CT scan

27. Ureteric Stones – Medical Treatment
Plenty of water orally.
Diuretic — Oral - frusemide to
flush the stone.
Suitable antibiotics to control
sepsis; antispasmodics to relieve
pain.
IV fluids — fast infusion of about
1.5 to 2 litres & IV frusemide (60-
80mg) given for 3-5 days.
Surgical intervention for ureteric
stones.

28. Ureteric stones – Surgical Treatment
 Stone is too large to pass > 5 to 8 mm
 IVU showing deterioration of function
 Co-existing infection
 Stone is impacted in the ureter with
persistent symptoms

30. Complications – Stones
 Obstruction
 Hydronephrosis
 Infection
 Impaction
 Ureteral stricture

31. Staghorn Calculus
It is the stone occupying the
renal pelvis and calyces.
It is usually calcium,
ammonium, mag. phosphate
(Triple phosphate) stone.
It is white in colour, soft,
smooth, occurs in pre- existing
infection (commonly E. coli).
It can be unilateral (or) bilateral.

32. Staghorn Calculus – Investigations
 U/S - Abdomen.
 Plain X-ray - KUB.
 IVU – renal function.
 Blood urea / Sr. creat.
 Urine micro.| C/S.

33. Staghorn Calculus – Treatment
Initially Antibiotic is started.
1. Unilateral stone is removed by nephro-
pyelolithotomy.
2. In bilateral cases IVU is very essential.
The kidney which is functioning better
should be treated first. After 3 months,
the other side kidney should be operated
upon.
3. Presently, PCNL is becoming popular
procedure for unilateral or bilateral
staghorn calculi.
4. In cases of severe infection –
Nephrectomy is required.

34. Prof. U. Murali.
Vesical Calculus

35. Vesical Calculus - Types
• Occurs in sterile
urine.
• Usually comes
down from kidney
& it gets enlarged
here.
• It is usually
oxalate stone (Jack
stone).
• It is usually single,
primary stone,
brownish black in
• Occurs in the presence of
infection. Most common
bladder stone.
• It is usually phosphate
stone, occurs in bladder
only.
• It is either calcium
phosphate (or)
ammonium, calcium and
magnesium phosphate
(Triple phosphate stone).
• E. coli is the common
organism.
Primary Secondary
• Uric acid and urate stones:
are single or multiple, radio-
luscent, smooth, pale yellow in
colour.
• Cystine calculus: Occurs in
cystinuria and is radio-opaque
due to high sulphur content.

36. Vesical Calculus – Etiology
• Infection
• Hypercalciuria / Hyperoxaluria /
Cystinuria
• Bed ridden and paraplegic patients
• Gout and other hyperuricaemic patients
• Diverticula bladder
• Obst. - urine flow by BPH, urethral
stricture, bladder neck obstruction
• Neurogenic bladder
• Schistosomiasis
• Foreign body in bladder

37. Vesical Calculus – C / F
• More common in males than females.
• Frequency - Earliest symptom – It is more
during day than night, because due to
ambulation stone comes in contact with the
trigone of the bladder and irritates.
• Pain: at the end of M. which is referred to
the tip of penis (or) labia.
• Haematuria: Often terminal.
• Hesitancy, Urgency & Intermittency.
• Features of cystitis: Burning micturition,
fever, pain.
• P/R or P/V: Large stone may be palpable.

38. Vesical Calculus – Investigations
• Urine microscopy - UFME.
• Urine C/S.
• Blood urea, serum creatinine, serum
calcium, inorganic phosphate, uric
acid.
• Plain X-ray, KUB shows radio-opaque
stones—90% are radio-opaque.
• IVU to see function of the kidney.
• U/S abdomen is diagnostic.
• Cystoscopy to see radiolucent stone.

39. V. Calculus – Treatment
• Cystoscopic litholapaxy
Under GA, cystoscope is passed - stone is
visualised. It is fragmented by pneumatic, laser,
electromagnetic waves (or) mechano-hydraulic
lithotripsy.
• Suprapubic open cystolithotomy
Through suprapubic incision, bladder is
identified & is opened near the fundus and
stone is removed.
• Suprapubic percutaneous lithotomy
When cystoscope cannot be passed per urethra,
bladder is approached suprapubi cally. Through
a needle, guidewire and dilators, a track is
created through which a nephroscope is passed
to remove the stone after fragmenting.

40. Recurrence of Stones – Prevention
 One should drink plenty of water - Per day 3 to 4 litres.
 Diet: Avoid excess - amounts of milk products,
strawberries, plums, spinach, tea, cola & meat.
 Drugs: According to the disease.
Allopurinol – Hyperuricaemia.
Pencillamine – Cystinuria.
Bendrofluzide – Idiopathic Hypercalciuria.
 Urine should be screened for infection.
 Investigations - in bilateral & recurrent stone formers:
• Serum calcium - fasting on 3 occasions - exclude
HPT.
• Serum uric acid.
• Urinary urate, Ca & PO4 in a 24-hour collection.
• Analysis of any stone passed.

41. References

42. To Summarize
 D/D of Renal colic.
 Mechanism of renal stone formation.
 Etiology, types, C/F of Renal & Ureteric calculus.
 Medical & Surgical treatment of Renal & Ureteric calculus.
 Types, etiology, C/F & management of Vesical calculus.
 Preventive aspects of recurrence of urinary stones.
 Complications of renal stones & Stag-horn calculus.

43. Question Time
 List 5 D/D of left renal colic in a male patient.
 Outline the stages in the formation of renal stone.
 Mention 3 indications & contraindications of ESWL & PCNL.
 Enumerate 5 etiological factors of renal calculus.
 Mention the surgical treatment of ureteric stones – at various levels.
 List 5 salient clinical features of vesical calculus.
 Outline the management of stag-horn calculus.
 Identify 5 life-style modifications to prevent kidney stones.

44. The ureter is narrow at all the following
sites, except:
 A. At the ureteric orifice.
 B. At the point of crossover of the iliac artery.
 C. At the point of crossover of the terminal ileum.
 D. At the ureteropelvic junction.

45. A 26-year-old man is diagnosed to have a 3 mm
stone in the upper calyx of the right kidney. The
treatment approach should be -
 A. Percutaneous nephrolithotomy.
 B. Shock wave lithotripsy.
 C. Open pyelolithotomy.
 D. Conservative treatment.

46. “Stag-horn” calculi are usually:
 A. Phosphate.
 B. Oxalate.
 C. Urate.
 D. Cystine.

47. Secondary vesical calculus refers to stones
formed due to:
 A. Hypercalciuria.
 B. Infection.
 C. Injury.
 D. Migrating from above.

48. Which one of the following stones is hard
to break by ESWL? :
 A. Calcium oxalate monohydrate.
 B. Calcium oxalate dehydrate.
 C. Uric acid.
 D. Struvite.

49. Which of the following advises is not given to a 35
years old female patient with recurrent renal
stone? -
 A. Increase water.
 B. Restrict salt.
 C. Restrict protein.
 D. Restrict calcium.

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