urolithiasis full undergraduate 3rd.pptx

urolithiasis

1. UROLITHIASIS URINARY STONES Prof./ Abdellatif Zayed Urology Department , Faculty of Medicine , Zagazig University

2. Objectives Etiology of stone formation Types of urinary stones Manage a case of acute renal colic Diagnosis Treatment Calcular anuria. When referral to a urologist is warranted? Preventive measures to avoid recurrence

3. Urinary stones are the third most common urinary tract disease exceeded by UTI and BPH 2-4% of general population Male : female 3:1 Age: 20:40 year old Family history is + ve in 25% Incidence

4. Etiology Excess urinary calcium Excess urinary oxalates Excess uric acid Excess cystine Infection with urea splitting organisms

5. Types of Urinary Stones Calcium containing stones: Calcium oxalate stone Calcium phosphate stone Infection stone (Struvite stone) Non-calcium containing stones: Uric acid stone Cystine stone

6. Cystine stone A rare faint radiopaque stone appears as ground-glass in KUB. Formed in acidic urine

7. A radio opaque stone and form in alkaline urine Due to infection by urease producing organisms The urease splits urea so ammonium is formed Chemical analyses of the stones shows: c alcium, m agnesium, a mmonium, and p hosphate (three cations and one anion) Forms stag horn stones Infection stone (Struvite stone)

8. Staghorn stone

9. Staghorn stone

10. Stag horn stone

11. Typically, radiolucent stone Formed in acidic urine Represent about 10% of cases. Uric acid stone

12. Clinical features

13. Renal pain: Colicky in nature Sudden onset and offset In the flank Not related to posture Referred to ipsilateral testis, labia majora Upper GIT symptoms (nausea and vomiting) History of similar attacks or stone passage Clinical features

14. Differential diagnosis of renal colic: Myalgia Radiculitis Appendicitis Intestinal obstruction

15. Complications : Obstructive uropathy Calculus anuria Renal failure. Infection Malignancy: SCC due to chronic irritation by long standing stone

16. Laboratory studies Urine analysis. Renal function tests (urea and creatinine) Uric acid Serum calcium Parathyroid hormone.

17. Plain X-ray of abdomen (KUB): Calcium containing stones: appear as radio opaque shadows (similar to the bone) Non-calcium containing stones (not seen in the film or appear faint as in case of cystine stone due to sulfur content) Imaging studies

18. KUB

19. DD of radio-opaque calculi in X ray: Phleboliths (calcified thrombi in pelvic veins) Gall bladder stones overlying right kidney Calcified mesenteric lymph nodes Pancreatic calcification Renal artery calcification

20. Abdominal ultrasonography The stone may be seen in the kidney, ureter or urinary bladder (Echogenic foci with posterior acoustic shadowing) 2ry sign as hydronephrosis or hydroureter due to obstruction

21. US

22. CT

23. CT without contrast (Spiral CT) The gold standard diagnostic tool. The single imaging technique in emergency diagnosis of acute renal colic Determine the size and location of the stone Assess the density of the  stone  in HU

24. Advantages of spiral CT Rapid procedure and no contrast Very high diagnostic accuracy It can show all types of stones Provide indirect signs on the degree of obstruction Provide information on non urinary causes

25. Intravenous urography (IVU) It is time consuming Contrast is nephrotoxic Not suitable in case of renal impairment Has been largely replaced by non-contrast CT

26. Medical treatment NSAIDs are effective in case of renal colic Morphine or pethidine may be required Chemolysis : alkalizing agents orally can dissolve uric acid stone Allopurinol for gout Treatment

27. A non-invasive outpatient procedure Shock waves generated outside the body are focused on the stone Shock wave energy fragments the stone to multiple small size gravels Renal stone < 2cm in a patent urinary tract is suitable for ESWL ESWL

28. ESWL is not suitable for Large stone Presence of distal obstruction

29. ESWL

30. Postoperative Complications: Steinstrasse (stone street) Perirenal Hematomas. (0.66%)

31. Per Cutaneous Nephro Lithotomy (PCNL) A tract is created percutaneously to the Kidney under X-Ray screening control

32. PCNL

33. Stone fragmentation tools Pneumatic lithotrite Laser lithotrite Ultrasound lithotrite

34. Open Surgery: Open surgery is rarely indicated Needs prolonged hospital stay

35. URETERAL STONE

36. URETERAL STONES Hospital admission is case of: Oral analgesics are insufficient Ureteral stone in a solitary Ureteral stone + UTI NSAIDs: first line ttt for pain Antiemetic:  IVF: in case of dehydration

37. Treatment of ureteral stone Alpha blockers: facilitate passage of stone ESWL: for stone in the upper ureter Endoscopy: for stone in the lower ureter Open surgery if there is ureteral stricture

38. Ureteroscopy

39. CALCULAR ANURIA Means NO urine flow from the kidney to the bladder because of obstruction of the both ureters / or the ureter of a single functioning kidney by calculi It is a serious urologic emergency

40. Investigations LAB studies: Blood urea Serum creatinine Potassium level Imaging studies: Ultrasonography KUB Non-contrast spiral CT

41. Treatment of calculary anuria By-pass the obstruction: Fixation of JJ stent or nephrostomy Remove the stone: After stabilization of general condition Manage post-obstructive diuresis

42. Bladder stone

43. Jackstone

44. Treatment Cystolitholapaxy : the stones to be broken and removed using a cystoscope Open Cystolithotomy

45. Immediate referral to urologist Medical analgesia is insufficient When sepsis is suspected UTI + obstructive uropathy Bilateral obstruction Calculary anuria Pregnancy or have delayed menstruation Comorbidities or > 60-year-old

46. Measures to prevent recurrence of stones Life style modification: Plenty fluid intake Fluids should be throughout the day Balanced diet: High in fiber and vegetables Normal calcium content Limited sodium and animal protein

47. Citrate supplementation and diuretics: Thiazide diuretics Allopurinol Citrate supplementation potassium levels and liver enzymes should be monitored to detect potentially serious adverse effects of citrate

48. Conclusions Urolithiasis is the third most common disease Causes: Ca, oxalate, uric acid, or UTI Clinical : renal colic + upper GIT symptoms Basic test: Urinalysis, US and spiral CT Medical ttt : NSAIDs, alkalinizing agents ESWL PCNL Endoscopy

49. Calcular anuria Immediate referral to urologist Measures to prevent recurrence of stones

50. Thank you