Urolithiasis

Urolithiasis
“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…”
-Hippocratic Oath
Prevalence
• F = French
• The French scale or French
gauge system is commonly
used to measure the size of
a catheter.
• Fr=1/3 mm.
Classification
Stones classified by aetiology:
Stone classified by chemical composition
By size:
By location:
• Stones can be classified according to anatomical position:
• Kidney: upper, middle or lower calyx; renal pelvis
• Ureter : upper, middle or distal ureter
• Urinary bladder.
By X-ray characteristics:
[kidney-ureter-bladder (KUB) radiography]
Pathogenesis
To summarize:
• A small crystal or foreign body promotes the crystallization and growth of a crystal
lattice in urine. And a matrix of organic urinary proteins that provides a framework
for the deposition of crystals.
• There are several urinary substances(magnesium, citrate etc.) which have been
demonstrated to inhibit crystallization of salts in urine. If these are in low
concentration or absent in urine, then there will be an increased tendency towards
stone formation.
• Stones tend to form at sites of obstruction. Examples would include a renal

calyceal diverticulum, a ureterocele, an obstructed bladder or an obstructed
prostatic duct.
Now let’s talk about each stone, how it’s
formed, its causes and its risk factors.
Calcium stones:
Calcium oxalate:
• Does hyperuricosuria promote calcium stones? We’ll talk about

that. [Spoiler: It does.]
Causes are:
magnesuria
•
Hypercalciuria
Absorptive:
Resorptive hypercalciuria
Primary
hyperparathyroidism.
• It is very rare to find the

classical changes of [osteitis
fibrosa cystica], where massive
collections of osteo-clasts cause
cystic cavities in bones and
sometimes a pathological
fracture.
• (Subperiosteal bone resorption)
Secondary and tertiary
hyperparathyroidism:
Hyperoxaluria
What about uricosuria?
• Several theories have been proposed to explain the possible mechanism
of calcium stone formation in hyperuricosuric patients.
1. Epitaxy, the formation of one crystal on top of another, related to
heterogeneous nucleation.
2. Addition of crystalline sodium urate (but not uric acid) accelerated
crystallization of calcium oxalate from a metastable solution
Further explanation on point 2:
• Salting out is a decrease in solubility of a non-electrolyte with increasing
concentrations of electrolyte, causing the former to precipitate from solution.
In the current example, calcium oxalate is poorly soluble and uncharged and
is considered the non-electrolyte, while uric acid is the more soluble, charged
electrolyte that causes precipitation of calcium oxalate.
• For more on this subject:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4514566/#S2title
Calcium phosphate:
Type 1 (
Uric acid stones:
as a
consequence of an abnormally rapid metabolism of nucleoprotein **or cytotoxic drugs not sure**). It
Struvite stones (infection
or triple phosphate
stones):
Cystine stones:
History and
examination
{symptoms & signs}
Symptoms
Pain
• Small
large
severity
increase
HEMATURIA
UTI
Fever
• Signs sepsis
Bladder stones
Other questions to ask in taking history:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1508366/
Signs and physical examination
• When assessing a patient clinically with a suspected diagnosis of
urinary tract stones always bear in mind that a potentially more
serious gastrointestinal, gynecological or vascular diagnosis may
be present, and these possibilities must be excluded especially
where conservative treatment is likely to be initiated for
presumed stone disease.
DIFFERENTIAL DIAGNOSIS
Other differential diagnosis
Investigations
Urinalysis
Radiological imaging
KUB
Ultrasound scan
Stones:
Right Ureteral Jet, absent Left
Ureteral Jet
Intravenous urography (IVU)
Computerized tomography urography
(CTU)
Bilateral
Static renography using DMSA scan
Other imaging studies:
Management
Conservative
Extracorporeal shock wave
lithotripsy (ESWL)
( )
Other limitations:
Double J stents
• Stone-free rates depends on :
• Stone size.
• Location.
• Composition.
• Stone-free was defined as no residual stones remaining after surgery.(?)

• [further explanation need to be kindly provided/explained by the doctor]
Pre ESWL KUB Post ESWL KUB
Intracorporeal techniques of stone
fragmentation
Ureteroscopy
Indications for flexible ureteroscopic:
Percutaneous nephrolithotomy (PCNL).
How?
Contraindications:
Complications: [European Association of Urology 2020]
extravasation of urine from a disruption of the urinary collecting

system at any level from the calix to the urethra
Pre-op IVP Post-op IVP
Next slide
Laparoscopy and open surgery
Complications
Medical Therapy
• Uric acid stones :

• Cystine stones
Medical expulsive therapy
[European Association of Urology 2020]
Management of sepsis and/or anuria in
obstructed kidney
To summarize
Prevention

Urolithiasis

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Urolithiasis

• Stones tend to form at sites of obstruction. Examples would include a renal

• Does hyperuricosuria promote calcium stones? We’ll talk about

• It is very rare to find the

• Stone-free was defined as no residual stones remaining after surgery.(?)

extravasation of urine from a disruption of the urinary collecting

• Uric acid stones :

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