Urinary calculi

urinary stones

1. 1
Dr sumer yadav

2. INTRODUCTION
•The diagnosis and management of urolithiasis
have undergone considerable evolution in
recent years. The application of noncontrast
helical computed tomography (CT) in patients
with suspected renal colic is one major advance.
The superior sensitivity and specificity of helical
CT allow urolithiasis to be diagnosed or
excluded definitively and expeditiously without
the potential harmful effects of contrast media.
2

3. INTRODUCTION (cont.)
•Initial management is based on three key
concepts: (1) the recognition of urgent and
emergency requirements for urologic
consultation, (2) the provision of effective pain
control using a combination of narcotics and
nonsteroidal anti-inflammatory drugs in
appropriate patients and (3) an understanding of
the impact of stone location and size on natural
history and definitive urologic management.
3

4. 4

5. EPIDEMIOLOGY
•One person in 10 develops kidney stones during
his/her lifetime in North India. Renal stone
disease accounts for 7-10 of every 100 hospital
admissions. Most common form of urinary
calculi in India is pure Calcium Oxalate 86.1%.
•Stone disease is two to three times more
common in males than in females. It occurs more
often in adults than in elderly persons, and more
often in elderly persons than in children.
5

6. •In addition, urolithiasis occurs more
frequently in hot, arid areas than in
temperate regions.
•Decreased fluid intake and consequent urine
concentration are among the most important
factors influencing stone formation. Certain
medications, such as triamterene (Dyrenium),
indinavir (Crixivan) and acetazolamide
(Diamox), are also associated with urolithiasis.
EPIDEMIOLOGY cont.
6

7. ETIOPATHOGENESIS OF STONE DISEASE
•Supersaturation of urine is the key to stone
formation
•Intermittent supersaturation - Dehydration
•Crystal aggregation
•Anatomic Abnormailities – PUJ
•Bacterial Infection
•Defects in transport of Calcium and Oxalate by Renal
epithelia
E.Coli infection increases matrix content in urine . Proteus makes
urine alkaline
7

8. TYPES OF KIDNEY / URETER STONES
•OXALATE (CALCIUM OXALATE)
•PHOSPHATE
•URIC ACID & URATE
•CYSTINE
8

9. UNCOMMON STONES
XANTHINE STONES
– (Autosomal Recessive . Def of Xanthine Oxidase leading to Xanthinuria)
DIHYDROXYADENINE STONE
– ( Def. of enzyme adenine phospo ribosyl transferase )
SlLICATE STONES
– Rare in humans ( excess intake of Antacid with Mg Trisilicate. Mostly in
cattle due to ingestion of Sand )
MATRIX
- Infection by Proteus - Radiolucent (all calculi have some amt ( 3%) of
matrix but matrix calculus has 65% Matrix content in calculi)
9

10. Uncommon Stones
TRIAMTERENE
– Anti-hypertensive used with hydroclorothiazide – spare Potassium.
Mostly found as a nucleus in Ca oxalate or uric acid calculus
Indinavir Stones
- Drug to treat AIDS (4 to13%)
Ephedrine or Guifenesin
– Cough medicine - Radiolucent
10

11. OXALATE (CALCIUM OXALATE)
•ALSO CALLED MULBERRY STONE
•COVERED WITH SHARP PROJECTIONS
•SHARP ® MAKES KIDNEY BLEED (HAEMATURIA)
•VERY HARD
•RADIO - OPAQUE
Under microscope looks like Hourglass or Dumbbell shape if monohydrate and
Like an Envelope if Dihydrate 11

12. PHOSPHATE STONE
•USUALLY ® CALCIUM PHOSPHATE
•SOMETIMES ® CALCIUM MAGNESIUM
AMMONIUM PHOSPHATE OR TRIPLE PHOSPHATE
•SMOOTH ® MINIMUM SYMPTOMS
•DIRTY WHITE
•RADIO - OPAQUE
Calcium Phosphate also called ‘Brushite’ appears like Needle shape under microscope
12

13. PHOSPHATE STONES
IN ALKALINE URINE
¯
ENLARGES RAPIDLY
¯
TAKE SHAPE OF CALYCES
¯
STAGHORN ®
Struvite can form Stag-horn and appear like coffin lid under microscope
13

14. URIC ACID & URATE STONE
•HARD & SMOOTH
•MULTIPLE
•YELLOW OR RED-BROWN
•RADIO - LUCENT (USE ULTRASOUND)
Under microscope appear like irregular plates or rosettes
pKa of uric acid 5.75 – at this pH 50% of uric acid insoluble.
If pH falls further - uric acid more insoluble 14

15. CYSTINE STONE
•AUTOSOMAL RECESIVE DISORDER
•USUALLY IN YOUNG GIRLS
•DUE TO CYSTINURIA -
•CYSTINE NOT ABSORBED BY TUBULES
•MULTIPLE
•SOFT OR HARD – can form stag-horns
•PINK OR YELLOW
•RADIO-OPAQUE
Under microscope appears like hexagonal or benezene ring – ask
for first morning sample 15

16. DIAGNOSIS AND INITIAL
MANAGEMENT OF KIDNEY
STONES
16

17. DIAGNOSIS
•Diagnosis of renal stone disease involves a
medical history, physical examination,
laboratory evaluation, and imaging tests.
The physician determines if the patient
has a history of kidney stones, documents
past medical conditions, and evaluates
present symptoms. Fever may indicate a
urinary tract infection that requires
antibiotics.
17

18. 18

19. THE DIAGNOSIS
•The various presentations of renal colic and
its broad differential diagnosis, an organized
diagnostic approach is useful.
•Symptomatic stones essentially present as
abdominal pain.
•Renal colic may be suspected based on the
history and physical examination, but
diagnostic imaging is essential to confirm or
exclude the presence of urinary calculi.
19

20. THE DIAGNOSIS cont.
•Several imaging modalities are
available, and each has advantages and
limitations (Table).
•Diagnostic imaging is essential to
confirm the size and location of urinary
tract calculi. A diagnosis of renal colic
cannot be based on the clinical findings
alone.
20

21. 21

22. URINALYSIS
•Urinalysis will be performed to look
for blood, infection or crystals in the
urine. It is common to see
microscopic traces of blood in the
urine when a kidney stone is
present, especially when it is moving
down the ureter.
22

23. Of currently available imaging
techniques, non-contrast helical
computed tomography has the
highest sensitivity and specificity
for the identification of urinary
tract stones. In the future, it will
probably become the imaging
technique of choice for suspected
renal colic. 23

24. MANAGEMENT STRATEGY
24

25. INTRODUCTION
•The management of urinary calculi
has undergone dramatic changes
since the early 1980s with the
introduction of extracorporeal shock-
wave lithotripsy (ESWL) using the
Dornier HM
3
device and with the
popularization of percutaneous
nephrolithotomy (PNL).
25

26. •After emergency situations have been ruled
out and adequate analgesia has been
achieved, the next step is to formulate a
strategy for managing the stone. Clinical
experience with urolithiasis has been refined
with statistical analysis to provide sound
principles for definitive management.
•The two major After emergency situations
have been ruled out and adequate analgesia
has been achieved, the next step is to
formulate a strategy for managing the stone.
26

27. •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.
27

28. MANAGEMENT OF RENAL STONE
•The characteristics of the stones
(size, number, location, and

composition), renal anatomy, and
clinical factors are all considered

when selecting a treatment
approach for renal calculi.
28

29. GENERAL MEDICAL TREATMENT
Medical therapy for stone disease serve two
purposes: -
Treatment of Acute Episode: - Specific guidelines
for emergency management are as follows: -
•Supranormal Hydration
•Analgesia: narcotic or nonsteroidal anti-
inflammatory drug (NSAIDs)
•Antiemetic agents such as metoclopramide HCI
and prochlorperazine may also be added as
needed.
29

30. •The traditional out patient treatment indicated above
has recently been improved by the application of active
medical explosive therapy MET.
1.The calcium channel blocker nifedipine relaxes ureteral
smooth muscle and enhances stone passage.
2.The alpha blotters, such as terazosin, and the alpha-1
selective blockers, such as tamsulosin, also relax
musculature of the ureteral and lower urinary tract,
markedly facilitating passage of ureteral stones.
3.Analgesic therapy combined with MET dramatically
improves the passage of stones, addresses pain, and
reduces the need for surgical treatment.
30

31. MANAGEMENT OF RENAL CALCULI
•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.
31

32. RENAL CALCULI cont.
•The majority (about 80% to 85%) of "simple"
renal calculi can be treated satisfactorily with
ESWL. Several factors were associated with
poor results of ESWL, including large renal
calculi (mean, 20 mm), stones within
dependent or obstructed portions of the
collecting system, stone composition (mostly
calcium oxalate monohydrate and brushite),
obesity or a body habitus.
32

33. 33

34. PREOPERATIVE EVALUATION
•Patients who have radiographic or clinical
features suggestive of struvite, or in
whom infection is suspected, should
receive 2 weeks of broad-spectrum
antibiotics before surgery to reduce the
risk of sepsis. Parenteral antibiotics
should be administered preoperatively in
any patient in whom urinary infection is
suspected.
34

35. STONE FACTORS
•Stone factor included stone burden
(size and number), stone
composition, and stone location.
35

36. STAGHORN STONES
•The ideal management of staghorn calculi is
threefold. 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.
36

37. Surgical Management of Staghorn Calculi
•OPEN STONE SURGERY (OSS) : -
Overall, the stone-free rate after OSS
for struvite stones is about 85%.
37

38. VARIOUS OPEN SURGICAL TECHNIQUES
•PYELOLITHOTOMY: - Is effective, especially
with an extra renal pelvis.
•ANATROPHIC NEPHROLITHOTOMY: - Is used
with complex staghon calculi.
•RADIAL NEPHROTOMY: - Given access to
limited calyces of the collecting system.
•EXTENDED PYELOLITHOTOMY
38

39. •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.
39

40. Surgical Management of Staghorn Calculi Cont.
•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.
40

41. Treatment Decisions by Stone
Composition
•Cystine and brushite stones are the most
resistant to ESWL, followed by calcium oxalate
monohydrate stones.
•Generally, stones that fragment with difficulty
(i.e., brushite, cystine, calcium oxalate
monohydrate) should be treated with ESWL only
when they are small (i.e., less than 1.5 cm).
Larger stones are preferentially treated with PNL
or RIRS.
41

42. Treatment Decisions by Renal Anatomy
•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, PNL with concomitant
endopyelotomy can achieve good results with
less morbidity.
42

43. Treatment Decisions by Renal Anatomy Cont.
•Horseshoe Kidney and 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, PNL should be used as the primary
approach.
•Ectopic Kidney : - Treatment of choice ESWL
Alternatively, percutaneous transperitoneal
nephrolithotomy can be done.
43

44. •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%.
44

45. •The efficacy of PNL 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 PNL should be considered the
primary approach for LPS larger than 10 mm.
45

46. TREATMENT DECISIONS BY CLINICAL FACTORS
•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 PNL and ureteroscopy
using flexible instruments, may be preferable
in these patients.
46

47. URETERAL CALCULI
•The goal of surgical management of ureteral
calculi is to achieve complete stone clearance
with minimal morbidity to the patient.
• Most ureteral calculi are 4 mm or smaller and
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.
47

48. 48

49. Referral to a urologist is
appropriate for patients with a
ureteral stone more than 5 mm in
greatest diameter or a stone that
has not passed after two to four
weeks.
49

50. 50

51. •Ureteral calculi are stones that usually
form in the renal collecting system, then
progress down the ureter. They tend to
become lodged at sites where the ureter
narrows. The three most common
entrapment sites are at the ureteropelvic
junction, over the iliac vessels and at the
ureteral meatus.
51

52. 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.
52

53. Cont.
4)Stone composition: - Brushite, cystine,
and calcium oxalate monohydrate are
relatively resistant to ESWL.
53

54. CLINICAL FACTORS
•Pain: - The pain of ureteral colic is
mediated by prostaglandins released by
the ureter in response to obstruction.
•Infection associated with ureteral
stones or obstructed pyelonephritis is a
relatively common and potentially life-
threatening urologic emergency.
54

55. Infection associated cont.
•Patients are typically febrile and may
present with hypotension or septic shock.
Urgent drainage of the obstructed portion
of the urinary tract by either ureteral
catheter or percutaneous nephrostomy is
essential. A urine culture from the
obstructed segment will aid in directing
antibiotic therapy.
55

56. SOLITARY KIDNEY
•A ureteral stone obstructing a
solitary kidney demands prompt
attention with drainage internally
via a stent and definitive stone
treatment (ESWL or URS).
56

57. 57

58. •Accepted alternatives for 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)Ureteroscopy (URS);
4)Percutaneous nephrolithotomy (PNL); and
5)Open surgery (referring to any method of open
surgical exposure of the ureter and removal of
stones)
58

59. PROXIMAL URETERAL STONES
•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.
59

60. PROXIMAL URETERAL STONES cont.
•Ureteral stenting is appropriate for
other indications, such as
management of pain, relief of
obstruction, and difficult-to-visualize
stones, and is mandatory in patients
who have a solitary obstructed
kidney.
60

61. DISTAL URETERAL STONES
•Surgical treatment options for distal
ureteral stones include ESWL 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.
61

62. BLADDER CALCULI
•Vesical calculi affect men predominantly and
account for 5% of urinary calculi in the Western
world. In the United States, bladder stones usually
occur in men older than 50 years and are often
associated with bladder outlet obstruction.
•Risk factors for bladder calculi include bladder
outlet obstruction; neurogenic bladder; chronic
bacteriuria (urea-splitting organisms); foreign
bodies; bladder diverticula; and, rarely, upper
tract stones.
62

63. BLADDER CALCULI CONT.
•Cystoscopy is essential to evaluate
the bladder and the bladder outlet,
both to determine the etiology of the
stone and to plan the most
appropriate treatment approach.
63

64. TECHNIQUE
•As with any urinary tract stone, the
first priority in treatment is to render
the patient stone free. However,
relief of bladder outlet obstruction,
elimination of urinary infection, and
correction of urinary stasis should
also be addressed as part of the
treatment plan.
64

65. TECHNIQUE cont.
•Several modalities exist for the
treatment of bladder calculi, including
cystolitholapaxy; cystolithotripsy with
electrohydraulic, ultrasonic, laser, or
pneumatic lithotripsy; percutaneous
cystolithotomy; and open
cystolithotomy. Shock-wave lithotripsy
may be another option.
65

66. •Cystolitholapaxy: - with stone-crushing forceps
or the optical lithotrite has been used to crush
stones since the late 1800s. Contraindications
to this procedure include small-capacity
bladders, multiple stones, stones larger than 2
cm that cannot be engaged, hard stones,
bladder stones in children, and inadequate
urethras.
•cystolitholapaxy can be technically difficult and
is associated with a complication rate of
between 9% and 25%.
66

67. •Percutaneous cystolithotomy has been advocated
as an alternative to open cystolithotomy in
pediatric patients with narrow urethras and in
patients with impassable or surgically ablated
urethras and bladder necks, large stone burdens, or
multiple stones with anticipated prolonged
operative times.
•Contraindications to this approach include history
of bladder malignancy, prior abdominal or pelvic
surgeries, prior pelvic radiotherapy, active urinary
or abdominal wall infection, and pelvic prosthetic
devices
67

68. •Open cystolithotomy may be indicated
in cases of large stone burdens or hard
stones refractory to an endoscopic
approach, abnormal anatomy
precluding safe access, or concomitant
open prostatectomy or
diverticulectomy.
•ESWL is safe and effective in non-
obstructed patients.
68

69. REVIEW OF MANAGEMENT IN STONE
(RENAL, URETERAL & BLADDER )
69

70. •IN BRIEF MANAGEMENT OF STONE IS
DONE BY FOLLOWING PROCEDURES: -
–MEDICAL TREATMENT
–OPEN SURGERY
–NON INVASIVE TECHNIQUE (ESWL)
–MINIMAL INVASIVE TECHNIQUE (RIRS,
PCNL, LAP.)
70

71. OPEN SURGICAL TREATMENT INDICATION
Some type of surgery may be needed to remove
a kidney stone if the stone:
•Does not pass after a reasonable period of time
and causes constant pain,
is too large to pass on its own.
•Blocks the urine flow.
•Causes ongoing urinary tract infection.
•Damages the kidney tissue or causes constant
bleeding, or has grown larger (as seen on follow
up x-ray studies).
71

72. •Until recently, surgery to remove a
stone was very painful and required
a lengthy recovery time (4 to 6
weeks). Today, treatment for these
stones is greatly improved. Many
options exist that do not require
major surgery.
72

73. EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY
•Extracorporeal shockwave lithotripsy (ESWL)
is the most frequently used surgical
procedure for the treatment of kidney
stones. ESWL uses shockwaves that are
created outside of the body to travel
through the skin and body tissues until the
waves hit the dense stones. The stones
become sand-like and are easily passed
through the urinary tract in the urine.
73

74. 74

75. EXTRACORPOREAL SHOCK-WAVE
LITHOTRIPSY
•That sound waves are focusable has been
known for centuries.
•Simple renal calculi are those with a stone
burden of <2

cm (aggregate diameter) and
normal renal anatomy. Most simple

renal
calculi (80-85%) can be treated successfully
with shock

wave lithotripsy (fig.).
75

76. •Lithotripsy may fail or

be less effective
when stones are larger; stones are
located

in dependent or obstructed parts
of the collecting system; stones

are
made up of calcium oxalate
monohydrate, brushite, or cystine;

the
patient is obese or has a body build that
inhibits proper

imaging; or it is difficult
to target the stone for shock wave

delivery and subsequent fragmentation.
76

77. •A retrospective

comparison of
percutaneous nephrolithotomy and
shock wave lithotripsy

found that as
stone burden increased, the number of
lithotripsy

treatments and ancillary
procedures increased, but stone-free

rates decreased.
77

78. 78

79. •There are several types of ESWL devices.
One device positions the patient in the
water bath while the shock waves are
transmitted. Other devices have a soft
cushion or membrane on which the patient
lies. Most devices use either x-rays or
ultrasound to help the surgeon pinpoint
the stone during treatment. For most types
of ESWL procedures, some type of
anesthesia is needed.
79

80. •In some cases, ESWL may be done on an
outpatient basis. Recovery time is short, and most
people can resume normal activities in a few
days.
•Complications may occur with ESWL. Most
patients have blood in the urine for a few days
after treatment. Bruising and minor discomfort
on the back or abdomen due to the shockwaves
are also common. To reduce the chances of
complications, doctors usually tell patients to
avoid taking aspirin and other drugs that affect
blood clotting for several weeks before
treatment.
80

81. •In addition, the shattered stone fragments
may cause discomfort as they pass through
the urinary tract in the urine. In some cases,
the doctor will insert a small tube called a
stent through the bladder into the ureter to
help the fragments pass. Sometimes the
stone is not completely shattered with one
treatment and additional treatments may
be required.
81

82. PERCUTANEOUS NEPHROLITHOTOMY
•Percutaneous nephrolithotomy is
recommended to remove a stone.
This treatment is often used when the
stone is quite large or in a location
that does not allow effective use of
EWSL.
82

83. •In this procedure, the surgeon makes a tiny
incision in the back and creates a tunnel directly
into the kidney. Using an instrument called a
nephroscope, the stone is located and removed.
For large stones, some type of energy probe
(ultrasonic or electrohydraulic) may be needed
to break the stone into small pieces. Generally,
patients stay in the hospital for several days and
may have a small tube called a nephrostomy
tube left in the kidney during the healing
process.
83

84. •One advantage of percutaneous
nephrokithotomy over ESWL is
that the surgeon removes the
stone fragments instead of relying
on their natural passage from the
kidney.
84

85. URETEROSCOPIC STONE REMOVAL
•Although some ureteral stones can be
treated with ESWL, urethroscopy may be
needed for mid- and lower ureter
stones. No incision is made in this
procedure. Instead, the surgeon passes a
small fiberoptic instrument called a
ureteroscope through the urethra and
bladder into the ureter.
85

86. •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.
86

87. OPEN SURGICAL TECHNIQUES
•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.
87

88. POSTOPERATIVE
•Hospital stays range from 3 to five
days depending on the type of
surgery. Postoperative pain is
typically mild to moderate and is
easily controlled with intravenous or
oral pain medication. An epidural
anesthetic can also be used to control
postoperative pain.
88

89. PREVENTION OF STONE RECURRENCE
•General Measures of Prevention
A.HYDRATION: - high fluid intake results in
reduction of saturation of calcium phosphate
calcium oxalate
B.DIET
A.Control Dietary protein
B.Control Dietary calcium
C.Control Dietary sodium
D.Control Dietary oxalate
E.Control Dietary phosphate
89

90. 90

91. SUMMARY POINTS
•Unenhanced helical computed
tomography is the

best radiographic
technique for diagnosing urolithiasis
•Shock

wave lithotripsy,
ureteroscopy, and percutaneous
nephrolithotomy

have replaced open
surgery for treating urolithiasis
91

92. SUMMARY POINTS
•Most simple

renal calculi (80-85%) can be
treated with shock wave lithotripsy
•Percutaneous

nephrolithotomy is the
treatment of choice for complex renal

calculi
•Staghorn calculi should be treated, and
percutaneous

nephrolithotomy is the
preferred treatment in most patients
92

93. SUMMARY POINTS
•Ureteroscopy

is the preferred
treatment in pregnant, morbidly
obese, or patients

with coagulopathy.
•Most ureteral calculi <5 mm in
diameter

will pass spontaneously
within four weeks of the onset of
symptoms.
93

94. THANKS
94