UROLITHIASIS

Supervised by:
Assoc. Prof. Dr Mohd Nazli bin Kamarulzaman
 Table of contents

01 Case Presentation 02 Introduction

Clinical Diagnostic
03 04 05 Management
Features Investigation
 01

Case Presentation
Mohamad Izzul Iffat Bin Ahmad Sukri (1911149)
Muhammad Eizaz Danish bin Baharuddin (1916015)
 Chief Complaint

Mdm R, 49 years old Malay lady, with underlying hypertension and

diabetes mellitus, electively admitted for surgical procedure in view of
intermittent dysuria for 1 year.
 History of Presenting Illness
Dysuria for 1 year ● No nausea and vomiting
● Burning sensation during micturition ● No LOA & LOW
● Intermittent ● No leg swelling
● A/W sandy urine sensation ● No uremic sx: muscle cramps, itchiness,
confusion, metallic taste
Associated symptoms
● hematuria ( mixed with urine) Risk factors
● Increase in frequency (7-10/day) ● Recurrent UTI
● Nocturia (3-4/day) ● No history of trauma
● Urgency ● No history of instrumentation
● No obstructive symptoms : Incomplete ● No known kidney abnormalities
voiding, terminal dribbling, straining, ● No history of spinal cord injury
incontinence ● No gouty arthritis
● No UTI symptoms: cloudy urine, ● Not taking calcium supplements or vit C
abdominal pain, fever ● No family members with renal stone or
● No constipation or diarrhea malignancy
 History of Presenting Illness
Past medical Family history
● Frequent visit to GP in view of UTI ● Father and mother alive, NKMI
and was treated with antibiotic ● 2/4 siblings, NKMI
for the past one year ● No similar problem
● Hypertension on perindopril 4mg, ● No gouty arthritis
atenolol 50mg ● No kidney stones or abnormalities
● Diabetes mellitus on metformin ● No malignancy
750 mg
● Compliance to medication & F/U Social history
● No CKD ● Housewife
● Not smoking
Past surgical history ● No high risk behaviour
● No
 Physical Examination
General Abdominal examination
● Medium-built woman Inspection
● Alert, conscious, pink, ● Flat, move with respiration
● No sallow face, no scratch marks ● No dilated veins, visible peristalsis
● Lying supine, not in pain ● No scars, no hernia
● No respiratory distress
● No conjunctival pallor Palpation
● Hydration status good ● Soft and non tender
● No lymphadenopathy ● Liver and spleen not palpable
● No bilateral pedal edema ● No palpable mass at right lumbar
● Both kidneys were not ballotable
Vitals
● Blood pressure: 159/85 mm/Hg Percussion
● Heart rate: 83 bpm ● Negative shifting dullness
● Respiratory rate: 19 bpm
● Temperature: 36.7C Auscultation
● Normal bowel sound
● No renal bruit & aortic bruit
 SUMMARY
Mdm R, 49 years old Malay lady, with u/l DM, HPT, HPL electively admitted for surgical
procedure in view with complaint of intermittent dysuria and sandy urine sensation for 1
year duration. It was associated with hematuria, increase in frequency, urgency, nocturia,
and incomplete voiding. No obstructive symptoms, UTI symptoms or constitutional
symptoms noted. On physical examination, there was no pallor. Abdominal examination was
normal.

Differential diagnoses:
1. Obstructive uropathy secondary to renal stone
2. Urinary tract infection
3. Ureteric stricture
4. Renal carcinoma
 INVESTIGATION
Liver function test:
Full Blood count X Ray KUB
● AST: 23
● Hb: 12.9 g/dL ● Features of
● ALT: 29
● WBC: 9.7 vesicolithiasis
● ALP: 92
● PLT: 311
USG KUB
Urine FEME
Renal Profile ● Vesicolithiasis
● Nitrite: -ve
● Na: 136
● Leukocytes: 2+
● K: 4.6 CT urography
● RBC: 61
● Cl: 102 ● urinary bladder
● WBC: 207
● Urea: 5.2 distended
● pH 4
● Creatinine: 78 ● vesicolithiasis
● EGFR: 77 measuring 1.2 x 2.0 x 1.6
Urine culture
● Uric acid: 426.6 cm
● Mixed growth (1 gram +ve
● No obstructive uropathy
and 3 gram -ve)
 MANAGEMENT

Analgesia: ● Plan for vesicolithotripsy

● T tramal 50 mg PRN ● Admit to ward

Oral Chemolysis ● Intraop finding:

● Ural effervescent granules 4g, 2 ○ Single stone sized 2cm
sachet per day ○ Bladder mucosa cystitis at
bladder necK
Urate lowering agent
● T. Allopurinol 300mg OD ● TCA urology clinic 2/12
○ With uroflow and PVR
Antibiotics: ○ Advised for low purine diet
● IV cefuroxime & gentamicin ○ Continue ural sachet &
allopurinol
 02
Introduction of
Urolithiasis
Muaz bin Mohd Radzi (1913763)
What is urolithiasis?
❏ Formation of calculi in urinary tract i.e. kidney, ureter
and bladder

Epidemiology
❏ Affects 12% of world population
❏ Depends on geographical, climatic, ethnic, dietary, and genetic factors
❏ Recurrence risk is determined by the disease or disorder causing the
stone formation.
❏ Prevalence rates vary from 1% to 20%.
❏ High standard of life countries (Sweden, Canada or the USA): renal stone
is > 10%.
❏ For some areas, an increase of more than 37% over the last 20 years.
❏ Emerging evidence linking nephrolithiasis to the risk of CKD.
How obstructive symptoms occur?
How irritative symptoms occur?
 Classification

Types Etiologies Urine Crystal Appearance Radiopacity

pH

Calcium Hypercalciuria, Acidic Monohydrate Radiopaque,

oxalate hypercalcemia, (dumbell) Dihydrate spherical,
(85%) hypocitraturia, hyperoxaluria (Envelope (X)) staghorn
(increased intake of ethylene rare
glycol or vitamin C, IBD due
to malabsorption)

Struvite/ UTI Alkalic Coffin-lid Radiopaque,

magnesium staghorn
ammonium common
phosphate
(5-15%)
 Classification
Types Etiologies Urine Crystal Radiopacity
pH Appearance

Uric acid Gout, hyperuricemia, Acidic Diamond, Radiolucent,

(10%) hyperuricosuria, high cell rhomboid staghorn
turnover (myeloproliferative possible
disorder, leukemia,
chemotherapy)

Calcium Renal tubular acidosis, Alkalic Amorphous Radiopaque,

phosphate hyperparathyroidism spherical
(<5%)

Cystine (1%) Cystinuria Acidic Hexagona Faintly

radiopaque,
staghorns
common
Quiz
 Risk factors
NON-MODIFIABLE MODIFIABLE

❏ Family History ❏ Obesity

❏ Climate ❏ Crystalluria
❏ Medical conditions ❏ Occupation
❏ Hyperparathyroidism ❏ Diet
❏ Nephrocalcinosis ❏ Medications
❏ Polycystic kidney disease - triamterene
❏ Increase vitamin D level - antacids
❏ Gout - Carbonic anhydrase inhibitor
❏ Diabetes mellitus (10-20% incidence)
❏ Urinary tract infection
❏ Anatomical abnormalities
❏ Medullary sponge kidney
Ureteropelvic/vesico junction
obstruction
❏ Urethral stricture
Pathophysiology
What about struvite stones?
Drug-induced stones?
 03

Clinical Features
Nur Fadhlin Nazhifah binti Mohd Uddad (1913248)
 Symptoms
Renal and Uteric Bladder Calculi
Calculi

● Pain ● Increased in frequency and

○ Renal stone -dull ache in the loin (space urgency of micturition
below 12th rib and iliac crest) ● Suprapubic ache
○ Ureter stone - ureteric colic ● Hematuria
● Hematuria
 Symptoms

Complications Symptoms

Urinary tract infection Fever, chills, dysuria

Renal failure Oliguria, leg swelling, uremia symtoms

 Signs

● There are rarely any physical signs, but very large stones can be felt on bimaunal
examination of the pelvis
● If patient has pyelonephritis, renal angle is very tender
● Ballotable kidney in hydronephrosis
 04
Diagnostic
Investigation
Muhammad Syahmi bin Suhaimi (1919713)
 OBJECTIVE

1. To confirm the presence and location of the stone

2. To evaluate any complication of stone
● On renal function and urinary tract morphology
3. To identify predisposing factors
● Structural and metabolic disorders
INVESTIGATIONS

Diagnostic - Imaging

Diagnostic - Metabolism related

Diagnostic - In special groups

 IMAGING

KUB Ultrasound KUB X-ray CT abdomen and Intravenous

(primary tool) pelvis urography (IVU)
 KUB Ultrasound
● Primary diagnostic imaging tool
● To determine:
○ Presence of stones
(calyces, pelvis, pyeloureteric &vesico-ureteral junctions)
○ upper urinary tract dilatation
●Sensitivity & Specificity:
○ 45% & 94% (ureteral stones)
○ 45% & 88% (renal stones)
● Advantages:
○ safe (no risk of radiation), reproducible
and inexpensive.
 KUB X-RAY

● Commonly done, non-invasive, readily available

- Radiopaque (90%) : calcium stone
- Radiolucent : urate stone
● If stones cannot be visualized, proceed to KUB ultrasound
 Non-Contrast-Enhanced
CT IMAGING of ABDOMEN and PELVIS

● To confirm the stone in acute flank pain

● Determine stone lcoation, density, diameter,
inner structure of stone, skin-to-stone distance &
surrounding anatomy
● Assist in the selection of treatment modality
● NCCT is significantly more accurate than IVU or US
 INTRAVENOUS UROGRAPHY

● Radiographic study of the renal parenchyma, pelvicalyceal

system, ureters and urinary bladder
● Consists of a preinjection KUB and further films at 5–20
minutes after injection of radiopaque contrast and after
micturition
● Radiopaque solution will opacifies the urinary system
●Can demonstrate level of obstruction
 METABOLISM RELATED

Basic laboratory Analysis of stone

analysis composition
BASIC LABORATORY INVESTIGATION

URINE BLOOD
 ANALYSIS OF STONE COMPOSITION

● Stone analysis should be performed on all first-time stone formers.

● In clinical practice, repeat stone analysis is needed in:
• recurrence under pharmacological prevention;
• early recurrence after interventional therapy with complete stone clearance
• late recurrence after a prolonged stone-free period
● The preferred analytical procedures are infrared spectroscopy (IRS) or X-ray
diffraction (XRD)
Specific Metabolic Evaluation
 IN SPECIAL GROUPS
Children
● Most common factor for stone formation
Pregnant Women -Vesicoureteral reflux
-Ureteropelvic junction obstruction
● Radiation: teratogenesis, carcinogenesis, -Neurogenic bladder
mutagenesis effects ● Complete a metabolic evaluation in all
● KUB Ultrasound : primary diagnostic children. (high risk of recurrence)
tools. ● Options:
● MRI : second line option - KUB Ultrasound is the primary imaging
-Determine the level of urinary tract - KUB X-Ray
obstruction - Intravenous urography (IVU) -need contrast
-Visualise stones - Low dose non contrast CT scan
-Gadolinium is not recommended ● Magnetic resonance urography (MRU)
● Low dose CT scan : last option -Cannot detect urinary stones.
-Provide anatomical information, location
of obstruction / stenosis.
05 MANAGEMENT
IFFAH NABIHA BINTI JOHARI (1915130)
 AIMS OF TREATMENT

Clearance of Relieve Reversal of

infection discomfort kidney function
impairment
ACUTE MANAGEMENT
 CONSERVATIVE MANAGEMENT

Medical Expulsive Therapy (MET) Oral Chemolysis

Aim: spontaneous stone passage 1. To dissolve stone composed of uric acid
(not for sodium or ammonium urate stone)
1. Stone ≤5mm → stone will pass spontaneously
2. Alkalinisation of urine by alkaline citrate
2. Stone >5mm and ≤10mm → tamsulosin 0.4 mg or sodium bicarbonate (ural)
OD 4/52
● other alpha blocker (terazosin, doxazosin,
alfuzosin)
● CCB (nifedipine)
● PDEI-5 (tadalafil)
● After 4 weeks repeat imaging to confirm
stone passage

3. Stone >10mm → need urology referral

 SURGICAL MANAGEMENT
Emergency → decompression with 1. Percutaneous nephrolithotomy (PCNL)
2. Ureteroscopy (URS) with ureteral stenting

Indications:
● Obstructing stones and suspected or confirmed UTI
● Bilateral obstruction and AKI
● Unilateral obstruction with AKI in a solitary functioning kidney

Elective → 1. Extracorporeal shock wave lithotripsy (ESWL)

2. Ureteroscopy (URS) with ureteral stenting
3. Percutaneous nephrolithotomy (PCNL)
4. Open stone surgery

Indications:
● Ureteral stones >10 mm
● Uncomplicated stones ≤10 mm that not passed after 4-6 weeks of observation, with or without MET
● Pregnant patients with ureteral or kidney stones with fail observation
● Persistent kidney obstruction due to stones
● Recurrent UTI due to stones
1. Extracorporeal shock wave lithotripsy (ESWL)
● Noninvasive method of destroying stones
using external shock waves to shatter the
stone aided by ultrasound or fluoroscopy
● Stone size up to 15mm
● Complication: infection, haematuria,
parenchymal haemorrhage, ureteric colic or
obstruction
● Contraindications: obese, pregnant and
patients on oral anticoagulants
 2. Ureteroscopy
● Examine the entire length of the ureter and
assist with stone removal using basket or
lithotripsy
● Ureteric stent placed in ureteric obstruction
● Complication: ureteric mucosal injury,
ureteric perforation and extravasation,
avulsion of the ureter and stricture
 3. Percutaneous nephrolithotomy (PCNL)
● Direct percutaneous access to the renal
pelvis using radiological or ultrasound
guidance.
● Small stones can be removed directly
● Larger stones can be broken into fragments
and then removed.
● Nephrostomy is left for 24-28 hours
● Indication: larger stone >20mm, staghorn
calculus and failure of ESWL and URS
● Complication: injury to the spleen, pleura
and colon, bleeding, urosepsis, rupture of
the collecting system and retained stone
fragments.
 4. Open Stone Surgery
● Not commonly done
● Indication: failure of other technique,
complex kidney stone and complex anatomy
abnormalities (bladder diverticula,
pelviureteric junction obstruction)
● Types:
○ Pyelolithotomy (pelvicalyceal system)
○ Ureterolithotomy (ureter)
○ Cystolithotomy (bladder)
LONG TERM MANAGEMENT

Metabolic Abnormalities:
● Hyperparathyroidism → parathyroidectomy
● Dietary hypercalciuria → lower dairy food intake
● Idiopathic hypercalciuria → thiazides
● Oxaluria → lower tea, coffee, chocolate, berries intake
● Hyperuricemia → allopurinol
 REFERENCE

1. Principles and Practice of Surgery

2. Bailey & Love's short practice of surgery
3. Essential Surgery: Problems, Diagnosis and Management
4. EAU Guideline on Urolithiasis 2022
5. Kidney stones in adults: Diagnosis and acute management of suspected
nephrolithiasis. UpToDate
6. Kidney stones in adults: Surgical management of kidney and ureteral stones.
UpToDate
Thank You
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