UROLITHIASIS

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UROLITHIASIS
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BACKGROUND

• Urinary stone disease continues to occupy an
  important place in everyday urological practice.
  The average lifetime risk of stone formation has
  been reported in the range of 5-10.
• A predominance of men over women (approx. 31)
  can be observed with an incidence peak between
  the fourth and fifth decade of life.
• Recurrent stone formation is a common problem
  with all types of stones and therefore an
  important part of the medical care of patients
  with stone disease.

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Theories of Stone Formation

• A. Nucleation Theory
• B. Stone Matrix Theory
• C. Inhibitor of Crystallization Theory
• Most investigators acknowledge that these 3
  theories describe the 3 basic factors influencing
  urinary stone formation. It is likely that more
  than one factor operates in causing stone
  disease. A generalized model of stone formation
  combining these 3 basic theories has been
  proposed.

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RISK FACTORS

• Start of disease early in life lt25 years
• Stone containing brushite
• Only one functioning kidney
• Disease associated with stone formation 
• - hyperparathyroidism 
• - renal tubular acidosis (partial/complete) 
• - jejunoileal bypass 
• - Crohns disease 
• - intestinal resection 
• - malabsorptive conditions 
• - sarcoidosis 
• - hyperthyroidism

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RISK FACTORS

• Medication associated with stone formation 
• - calcium supplements 
• - vitamin D supplements 
• - acetazolamide - ascorbic acid in megadoses ( gt
  4 g/day) 
• - sulphonamides - triamterene 
• - indinavir
• Anatomical abnormalities associated with stone
  formation
•  - tubular ectasia (medullary sponge kidney)
•  - pelvo-ureteral junction obstruction 
• - calix diverticulum, calix cyst
• - ureteral stricture 
• - vesico-ureteral reflux 
• - horseshoe kidney
•  - ureterocele

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Etiology (according Capital and I. Pogo Elko).

• F) Injuries those leads to continuous
  immobilization
• fractures of the vertebral column and limbs
• osteomyelitis
• diseases of the bones and joints
• chronic diseases of the visceral organs and
  nervous system.
• G) Climate and geographical causes.
• dry and hot climate with a high vaporization
• decrease water supply
• iodine deficiency
• H) Disorders of nutrition and vitamins balance
• retinole and oscorbine acid deficiency in food.
• Excessive amount of the ergocalciferole in
  organism.

• A). Disorders of urinary tract
• congenital abnormalities those favor to
  apostasies
• obstructive processes
• neurogenic duskiness of the urinary tract
• inflammative and parasitogenic damages
• foreign bodies of urinary tract
• traumatic injuries.
• B) Liver and digestive tract disorders
• latent and manifested hepathopathiy
• hepatogenic gastritis
• colitis, etc.
• C) Endocrine diseases
• hyperparathyreoidism
• hyperthyroidism
• hypopituitaric diseases
• D.) Infect focuses of the urogenital system.
• E) Metabolism disorders.
• essential hypercalciuria
• disorders of membranes for colloid substances
  diffusion

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Renal Calculi

• 1 Coral calculus
• 2 Coral calculi fragment
• 3 Calculi, which are impregnated with blood
  pigments

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Diagnostic imaging
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Medical History

• A personal as well as a family history should be
  obtained for all patients.
• A history of inflammatory bowel disease,
  recurrent urinary tract infection, prolonged
  periods of immobilization, gout, or familial
  occurrence of certain inherited renal diseases,
  eg, renal tubular acidosis or cystinuria, should
  be sought.

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Clinical Manifestations

• Acute obstruction of the urinary tract may cause
  renal colic, a form of severe abdominal pain
  often accompanied by nausea and vomiting due to
  celiac ganglion stimulation. Onset is sudden,
  often during the night or in the early morning

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Clinical Manifestations

• Obstructing calculi in the upper urinary tract
  cause an extreme crescendo like pain in the flank
  that generally radiates laterally around the
  abdomen to the corresponding groin and testicles
  in males and labia major in females.
• When the stone obstructs the midureter, the pain
  tends to radiate to the lateral flank and
  abdominal region.
• However, when the obstruction is in the distal
  ureter (near the ureterovesical junction), the
  patient exhibits symptoms of bladder irritation
  (frequency and urgency or genital pain).

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Clinical Manifestations

• Fever is rarely present except when a urinary
  tract infection accompanies obstruction.
• Pulse rate and blood pressure, however, may be
  elevated as a result of the pain and agitation
  caused by the renal colic.
• The patient's abdomen is generally flat and soft,
  with moderate deep tenderness on palpation where
  the calculus is lodged.
• Some patients also have extensive hyperesthesia
  of the abdominal wall, either anteriorly or
  posteriorly.
• The costo-vertebral area may be tender to
  percussion.

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Laboratry Investigations

• Stone analysis In every patient one stone
  should
• be
  analysed.
• Blood analysis Calcium Albumin
  Creatinine Urate
• Urinalysis Fasting morning spot urine
  sample
• Dip-stick test pH,
  Leucocytes/Bacteria
• Cystine test,
  Ca, P, citrate, urate

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Urinalysis.

• This test usually reveals either gross or
  microscopic hematuria. Although hematuria may be
  absent in complete obstruction, microhematuria
  may be present in symptomatic partial
  obstruction.
• Pyuria, usually moderate, may accompany
  obstruction even in the absence of identifiable
  infecting organisms. If severe pyuria is present,
  infection should be considered (especially in a
  female), since the stones may be secondary to
  infection.

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Diagnostic imaging

• Routine examination involves a plain
  abdominal film of the kidneys, ureters and
  bladder (KUB) At least 90 of all renal stones
  are radiopaque and therefore readily visible on a
  plain film of the abdomen

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Diagnostic imaging

• Excretory pyelography must not be carried out in
  the following patients - those
• With an allergy to contrast media
• With S-creatinine level gt 200 µmol/L
• On medication with metformin
• With myelomatosis

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Diagnostic imaging

• Special examinations that can be carried out
  include
• Retrograde or antegrade pyelography
• Retrograde pneumo-pyelography or cystography
• Spiral (helical) unenhanced computed tomography
  (CT)
• Scintigraphy.

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Diagnostic imaging

• Ultrasonography-
• In patients in whom it is not possible to
  obtain an intravenous urogram, ultrasonic
  evaluation of the kidneys may aid in the
  diagnosis of renal stones.
• In pregnant women with flank pain in whom it
  is desirable to limit radiation exposure or in
  anuric patients or patients with chronic renal
  failure, the presence of hydronephrosis on
  acoustic shadowing may be diagnostic.

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Diagnostic imaging

• Cystoscopia shows swallowing of the ureter
  orifice in lower location of the stone, it may
  also partially project out to the orifice.

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Cystoscopy
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TREATMENT

• Conservative
• Instrumental
• Surgical

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Pain relief

• Pain relief involves the administration by
  various routes of the following agents
• Diclofenac sodium
• Indomethacin
• Hydromorphone hydrochloride atropine sulphate
• Baralgin
• No-spae Analgine
• Tramadol

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Pain relief

• Warm bath
• Spasmolytic cocktails (with papaverine,
  spasmalgone, no-spanum, promedole) should be
  taken.
• A high dosage of the cystenal or urolesan (20
  drops on the piece of sugar) is rather effective
  at the start of the renal colic.
• If ache doesnt disappear the novocaine blockade
  of the spermatic cord in males and round ligament
  in females is required.
• Physical method.

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Pain relief

• For patients with ureteral stones that are
  expected to pass spontaneously, suppositories or
  tablets of diclofenac sodium, 50 mg administered
  twice daily over 3-10 days, might be useful in
  reducing ureteral oedema and the risk of
  recurrent pain. The patient should be instructed
  to sieve the urine in order to retrieve a
  concrement for analysis.

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Pain relief

• When pain relief cannot be obtained by medical
  means, drainage by stenting or percutaneous
  nephrostomy (PN) or stone removal should be
  carried out.

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Stone removal

• The size, site and shape of the stone at the
  initial presentation influence the decision to
  remove the stone. Also, the likelihood of
  spontaneous passage has to be evaluated.
  Spontaneous stone passage can be expected in up
  to 80 of patients with stones not larger than 4
  mm in diameter. For stones with a diameter
  exceeding 7 mm the chance of spontaneous passage
  is very low.
• The overall passage rate of ureteral stones is
• Proximal ureteral stones 25
• Mid-ureteral stones 45
• Distal ureteral stones 70

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Indications for Active Stone removal

• Stone removal is usually indicated for stones
  with a diameter exceeding 6-7 mm. Active stone
  removal is strongly recommended in patients
  fulfilling the following criteria
• Persistent pain despite adequate medication
• Persistent obstruction with risk of impaired
  renal function
• Stone with urinary tract infection
• Risk of pyonephrosis or urosepsis
• Bilateral obstruction.
• Obstructing calculus in a solitary functioning
  kidney

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Stone removal

• A test for bacteriuria should be carried out in
  all patients in whom stone removal is planned.
  Screening with dipsticks might be sufficient in
  uncomplicated cases. In others, urine culture is
  necessary. In all patients with a positive test
  for bacteriuria, with a positive urine culture or
  when there is suspicion of an infective
  component, treatment with antibiotics should be
  started before the stone-removing procedure.
• Bleeding disorders and anticoagulation treatment
  should be considered. These patients should be
  referred to an internist for appropriate
  therapeutic measures during the stone-removing
  procedure. Treatment with salicylates should be
  stopped 10 days before the planned stone removal.

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Indications to surgical operation

• Frequent attacks of the renal colic or persistent
  pain that disables the patient.
• Disorder of the urine outflow causing the
  hydronephrotic degeneration of the kidney.
• Obturative anuria.
• Frequent attacks of the acute pyelonephritis,
  progress of the chronic pyelonephritis that
  causes renal insufficiency.
• Total hematuria.
• Calculous pyonephrosis, apostematous
  pyelonephritis or carbuncle of the kidney.
• Stone at the sole kidney that causes obstruction.
• Stone in the ureter of the sole kidney that wont
  pass away spontaneously.

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Stone removal

• In patients with coagulation disorders the
  following treatments are contra-indicated
  extracorporeal shock wave lithotripsy (ESWL),
  percutaneous nephrolithotomy with or without
  lithotripsy (PNL), ureteroscopy (URS) and open
  surgery.
• In pregnant women, ESWL, PNL and URS are
  contra-indicated. In expert hands URS has been
  successfully used to remove ureteral stones
  during pregnancy, but it must be emphasized that
  complications of this procedure might be
  difficult to manage.
• In such women, the preferred treatment is
  drainage, either with a percutanous nephrostomy
  catheter, a double - J stent or a ureteral
  catheter .
• For patients with a pacemaker it is wise to
  consult a cardiologist before undertaking an ESWL
  treatment.

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Percutaneous Procedures

• Percutaneous nephrostomy. Because of this
  technique, urologists can now perform operative
  procedures within the kidney without using the
  standard large flank incisions and mobilization
  of the kidney.
• This technique, along with refinements in
  endoscopic instruments and advances in
  fiberoptics, allows endoscopic manipulation in
  the upper urinary tract by the percutaneous
  approach.
• Percutaneous nephrolithotomy with or without
  lithotripsy (PNL)

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Closed Surgical Procedures

• Cystoscopic technique With the patient under
  anesthesia and with fluoroscopic control, stones
  in the distal ureter can sometimes be removed
  with a wire stone basket
• Ureteropyeloscopy Manipulation of small
  ureteral stones under direct vision with a
  ureteroscope is a major advance in the management
  of ureteral calculi. With this technique, small
  stones can be easily trapped in a stone basket
  and safely extracted through the dilated ureter.
  

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Extracorporeal Shock Wave Lithotripsy

• An extracorporeal noninvasive technique that uses
  shock waves to disintegrate urinary calculi while
  the patient is immersed in a water bath has been
  tested extensively and is now in clinical use.
  With this technique, calculi in the upper urinary
  tract are reduced to fragments, which pass
  spontaneously from the collecting system and
  bladder in most patients.
• Size, location, and consistency of stone
  determine the number of shocks needed for
  fragmentation. In general, between 500 and 2,000
  shocks arc necessary to fragment and pulverize an
  intrarenal calculus sufficiently for complete
  passage.

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Open Surgical Procedures

• Pyelolithotomy Simple pyelolithotomy is used for
  removal of calculi confined to the renal pelvis.
  Minimal dissection of the renal sinus is usually
  needed, and exposure of the entire kidney is not
  required. This procedure is not indicated for
  the removal of entrapped caliceal stones or
  large, branched renal calculi.

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Open Surgical Procedures

• Ureterolithotomy. There are retroperitoneal,
  transperitoneal and combined surgical accesses.
  It depends on stone location. To remove stone
  from the superior ureter the Fedorovs access is
  used, from medial ureter Cuckulidzes or
  Derevyanko access is performed, the inferior
  ureter Pyrogovs access is needed, the pelvic
  portion of ureter may be accessed through the
  suprapubic arcuate incision.

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Open Surgical Procedures

• Nephrectomy Nephrolithotomy
  Cystolithotomy

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Preventive treatment in calcium stone disease

• Preventive treatment in patients with calcium
  stone disease should be started with conservative
  measures. Pharmacological treatment should be
  instituted only when the conservative regimen
  fails. Patients should be encouraged to have a
  high fluid intake. This advice is valid
  irrespective of stone composition. For a normal
  adult, the 24-h urine volume should exceed 2000
  ml, but the supersaturation level should be used
  as a guide to the necessary degree of urine
  dilution. The fluid intake should be evenly
  distributed over the 24-h period, and particular
  attention should be paid to situations where an
  unusual loss of fluid occurs.

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Preventive treatment in calcium stone disease

• Diet should be of a 'common sense' type - a mixed
  balanced diet with contributions from all food
  groups but without excesses of any kind. The
  intake of fruits and vegetables should be
  encouraged because of the beneficial effects of
  fibre. Care must be taken, however, to avoid
  fruits and vegetables that are rich in oxalate.
  Wheat bran is rich in oxalate and should be
  avoided. In order to avoid an oxalate load, the
  excessive intake of products rich in oxalate
  should be limited or avoided. This is of
  particular importance in patients in whom high
  excretion of oxalate has been demonstrated. The
  following products have a high content of oxalate
  
• Rhubarb 530 mg oxalate/100 g
• Spinach 570 mg oxalate/100 g
• Cocoa 625 mg oxalate/100 g
• Tea leaves 375-1450 mg oxalate/100 g
• Nuts 200-600 mg oxalate/100 g.

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Preventive treatment in calcium stone disease

• Vitamin C in doses up to 4 g/day can be taken
  without increasing the risk of stone formation.
  Animal protein should not be ingested in
  excessive amounts. It is recommended that the
  animal protein intake is limited to approximately
  150 g/day. Calcium intake should not be
  restricted unless there are very strong reasons
  for such advice. The minimum daily requirement
  for calcium is 800 mg and the general
  recommendation is 1000 mg/day. Supplements of
  calcium are not recommended except in cases of
  enteric hyperoxaluria, in which additional
  calcium should be ingested with meals.

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Preventive treatment in calcium stone disease

• The intake of foodstuffs particularly rich in
  urate should be restricted in patients with
  hyperuricosuric calcium oxalate stone disease ,
  as well as in patients with uric acid stone
  disease. The intake of urate should not be more
  than 500 mg/day. Below are examples of food rich
  in urate
• Calf thymus 900 mg urate/100 g
• Liver 260-360 mg urate/100 g
• Kidneys 210-255 mg urate/100 g
• Poultry skin 300 mg urate/100 g
• Herring with skin, sardines, anchovies, sprats
  260-500 mg urate/100 g.

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THANK YOU FOR ATTENTION