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BY JINU ALOYSIUS 2002 BATCH

AETIOLOGY & MANAGEMENT OF. RENAL STONES. BY JINU ALOYSIUS 2002 BATCH. HISTORICAL …. Renal stones has been detected in Egyptian mummies dated to 4800BC. In 12 th century BC Susruta performed perineal lithotomy.

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BY JINU ALOYSIUS 2002 BATCH

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  1. AETIOLOGY & MANAGEMENT OF RENAL STONES BY JINU ALOYSIUS 2002 BATCH

  2. HISTORICAL …. • Renal stones has been detected in Egyptian mummies dated to 4800BC. • In 12th century BC Susruta performed perineal lithotomy. • The specialty of urologic surgery was recognized even by Hippocrates (4th Century BC) who wrote, in his famous oath for the physician, “I will not cut, even for the stone, but leave such procedures to the practitioners of the craft”.

  3. EPIDEMIOLOGICAL ASPECTS • Prevalence: 0.1-0.4% of the population every year • Life Time Incidence: Upto 12% • Intrinsic Factors • Peak Age: 20-50 yrs (Onset mostly in their teens) • Sex (M/F) : 3:1 • Race: Whites >Blacks • Positive Family History: 25 fold higher incidence

  4. HEREDITARY • Family renal tubular acidosis: Nephrolithiasis, Nephrocalcinosis • Cystinuria • Xanthinuria • Dihydroxyadeninuria • X-linked hypercalciuric kidney stone syndrome/DENT’s DISEASE • X-linked recessive nephrolithiasis • X-linked hypophosphatemic rickets

  5. EXTRINSIC FACTORS • Geography – Higher in mountainous, desert or tropical areas - High incidence: North India, Pakistan, Britain, Mediterranean countries, North Australia, Central Europe - Low incidence: Central & South America, Africa • Climatic & Seasonal Factors – Higher in summer months. • Water Intake – Reduces stone formation (Hard water may ) • Diet – High intake of Calcium, Phosphate, oxalates, sodium, Vitamin A deficiency • Occupation – Sedentary occupation, astronauts after space flight • Stress – due to emotional life events, marriage problems.

  6. RENAL STONE COMPOSITIONS OXALATE – Calcium oxalate monohydrate, Calcium oxalate dihydrate PHOSPHATES – Hydroxy apatite, Carbonate apatite, Calcium hydrogen phosphate dihydrate (BRUSHITE), Tricalcium phosphate (WHITLOCKITE), Ostacalcium phosphate, Magnesium ammonium phosphate hexahydrate (STRUVITE), Magnesium hydrogen phosphate trihydrate (NEWBERYLITE) • URIC ACIDS – Anhydrous uric acid, uric acid dihydrate • URATES – Ammonium acid urate, Sodium acid urate monohydrate • CYSTINES • XANTHINES

  7. PATHOPHYSIOLOGY OF STONE FORMATION • NUCLEATION is a process, where by stone formation is initiated by the presence of a crystal or foreign body, which promotes the growth of salt crystals only in supersaturated urine. • In HETEROGENOUS NUCLEATION, nidus is composed of a substance other than the stone crystal eg-crystallisation on injured surface of renal tubular cells or different solute.

  8. Transiently or intermittently supersaturated urine is sufficient for nucleation. • Other factors – low concentration of CRYSTALLISATION INHIBITORS – Citrate, nephorcalcin, pyrophosphate, acidic glycopeptides, uropontin, magnesium • Altered pH – Significant effect – on solubility & crystallisation.

  9. Most crystals pass through the urinary system unless they are adherent to the renal collecting system or retained by urinary stasis. • In some instances, kidney stone can be attached to Randall’s plaques or sites of previous renal injury, preventing distal passage. • Anatomical factors such as distal obstruction (i.e.ureteral structure) or location in lower pole may lead to stasis & subsequent stone formation.

  10. CAUSES FOR STONE FORMATION • CALCIUM OXALATE STONE - Hypercalciuria – Absorptive hypercalciuria - Renal hypercalciuria - Resorptive hypercalciuria - Idiopathic hypercalciuria - Hypercalcemia – Primary hyperparathyroidism - Malignancy associated hypercalcaemia - Sarciodosis and other granulomatous diseases - Glucocorticoid – induced hypercalcemia - Pheochromocytoma - Familal hypocalciuric hypercalcemia - Immobilisation - Iatrogenic hypercalcemia – Thiazide, lithium, tamoxifen Excess vit D, Milk-alkali syndrome

  11. Hyperoxaluria - Increased oxalate production: : Primary hyper oxalauria : Increased hepatic conversion - Increased oxalate absorption : Enteric hyperoxaluria - Hyperoxaluria in idiopathic calcium oxalate stone disease • Sexhormones – testosterone increase urine oxalate excretion • Hypocitraturia – since uric acid can complex with calcium • Hypomagnesemia

  12. CALCIUM PHOSPHATE STONES • Hypercalciuria • Hypercalcemia • Nanobacteria – produces carbonate aptite at physiological pH. • Renal tubular acidosis. • URIC ACID STONES • Hyperuricosuria – Excess dietary purine intake • Excessively acidic urine • Secondary uric acid stones in Gout • Diminished urinary volume

  13. STRUVITE STONES (TRIPLE PHOSPHATE/ INFECTION STONES) • Accounts for majority of staghorn calculi • Urea splitting organisms includes gram negative, gram positive bacteria, mycoplasma and yeasts. Eg: Proteus mirabilis (most common), Klebsiella, Psudomonas, Ureoplasma ureolyticum • Urine pH > 7.2 and ammonia in Urine. • CYSTINE STONES • Cystnuria – Autosomal recessive disorder • DIHYDROXYADENINE STONES • Deficiency of enzyme adenine phsophoribosyl transferase

  14. XANTHINE STONES • Xanthinuria – deficiency of enzyme xanthine oxidase- Lesch – Nyhan syndrome • IATROGENIC STONES • Proteinaceus material and fungus balls in patients with prolonged courses of antibiotic therapy • SILICATE CALCULI • Intake of large amounts of antacids containing silicates • MATRIX CALCULI • Stone composed of coagulated mucoids in infection by urease producing organisms. • Usually associated with alkaline UTI.

  15. AMMONIUM ACID URATE CALCULI • Ureolytic infection in excess uricosuria • Urinary phosphate deficiency • Low fluid intake • DRUG INDUCED STONES • Antitussives containing ephedrine or guaiphenesin • Triamterene, a potassium sparing diuretic • Indinavir, a protease inhibitor for HIV • SPURIOUS CALCULI • Factitious, patients mimicking of having colic eg. Munchausen syndrome.

  16. CLINICAL PRESENTATION • ASYMPTOMATIC in 25% cases, may be discovered only incidently • PAIN – Classical ureteral colic is a sudden onset excruciating pain which is intermittent and radiates from loin to groin. • Severity of pain is not related to amount of distension but due to the rapidity with which it develops. • HAMATURIA – microscopie/gross (may be negative in 5% of cases) • PYURIA – limited and usually sterile

  17. NAUSEA & VOMITING – due to stimulation of coeliac plexus • FEVER – uncommon unless there is concomitant infection • STRANGURY – (painful passage of a few drops of urine) in intramural ureteric stones. • URINARY FREQUENCY & URGENCY – when stones are near bladder • COSTOVERTEBRAL ANGLE TENDERNESS is frequently observed

  18. RELATIONSHIP OF STONE LOCATION TO SYMPTOMS

  19. D/D – All other causes of acute abdominal pain should be ruled out. • COMMON LOCATIONS WHERE STONES GET IMPACTED. 1. Calyces 2. Ureteropelvic junction 3. At or near pelvic brim, where ureter begins to arch over the iliac vessels posteriorly into the true pelvis. 4. Posterior pelvis, especially in females where ureter is crossed anteriorly by the broad ligament. 5. Uretero vesical junction- most common site of impaction.

  20. INVESTIGATIONS • LABORATORY STUDIES • URINALYSIS • Haematuria •  Pyuria Usually mild • Significant pyuria with fever • Urine culture for UTI •  Urine pH pH> 7 suggests presence of urea splitting organisms and possible struvite stones •  pH<5.5 associated with uric acid stones •  Presence of crystals

  21.  Blood Complete blood count -Mild leucocytosis common  WBC>15,000/mm3 in obstructive /nonobstructive pyelonephritis  Serum electrolytes to identify acidosis, alkalosis or hypokalemia  RFT (Blood urea and serum creatinine )

  22. RADIOGRAPHIC EXAMINATION PLAIN ABDOMINAL FILMS of kidneys, ureters and bladder (KUB) Advantages  Readily available  Most useful in the follow-up of stones  Reasonably accurate in detection of radioopaque stones

  23. LIMITATIONS Radio lucent calculi cannot be visualized  Frequently observed by bowel gas  Ureteral stones overlying the bony pelvis or transverse process of vertebrae difficult to identify  Nonurologic radioopacities such as calcified mesenteric lymphnodes, gall stones, stool and phlebolith may be misinterpreted as stones  Inability to display renal anatomy and functions  Sensitivity and specificity of KUB is poor (Sensitivity-45-59%; specificity-71-77%)

  24. STONE COMPOSITION IN DECREASING ORDER OF RADIOOPACITY

  25. INTRAVENOUS UROGRAPHY • IVU has been the mainstay for renal stones because the study has high sensitivity (64-87%) and specificity (92-94%) for diagnosis of stones • Advantages •  Information about the stone (size, location, radio density) and its environment (calyceal anatomy, degree of obstruction) as well as the contralateral renal unit function, anomalies like medullary spongy kidney, ureteral stricture ureteral duplication or calyceal diverticulum •  Ureteral calculi can be easily distinguished from nonurologic radioopacities by this method

  26. LIMITATIONS • An unprepared study (without a prior mechanical bowel preparation) in the emergency department caused poor visualisation of retroperitoneal structures • Failure to visualize radiolucent stones but may demonstrate a filling defect. • Risks of contrast reaction and nephrotoxicity • Prolonged examination time , especially with a high grade obstructing stone – even prolonged reimaging at 12to 24 hrs may not demonstrate the level of obstruction because of inadequate concentration of the contrast medium.

  27. PRECAUTIONS: although a creatine level greater than 1.5 per dL (130mol per L ) is not an absolute contraindication, the risks and benefits of using contrast media must be carefully weighed, particularly in patients with DM, cardiovascular diseases or multiple myeloma. • These risks may be minimized by adequately hydrating the patient, minimizing the amount of contrast material that is infused, and maximizing the time interval between consecutive contrast studies. • It is prudent to avoid the use of contrast media when an alterative imaging modality can provide equivalent information.

  28. ROLE OF NONIONIC CONTRAST MEDIA : may decrease reactions such as nausea , flushing and bradycardia, but there is no apparent reduction of anaphylactic reactions or nephrotoxicity • A new concern has emerged because of reports of fatal metabolic acidosis after radiological procedures using I.V. contrast media in patients with DM with preexisting renal failure and who are taking metformin

  29. The basic mechanism of interaction involves impairment of renal metformin excretion by contrast media induced nephrotoxicity that results in elevated serum metformin levels • Therefore discontinue metformin at the time of or before a procedure using contrast material and to withhold the drug for 48 hours after the procedure. Metformin therapy is reinstituted only after renal function is reevaluated and found to be normal.

  30.  ULTRASONOGRAPHY • Ultrasound is a noninvasive method which is highly sensitive for renal calculi greater than 5 mm and for detecting consequent hydronephrosis ADVANTAGES • Non invasive quickly performed readily available in both hospital and outpatient setting • No radiation risk: has become the procedure of choice in pregnant women and pediatric population • Detects stones in the kidney and ureterovesical function with reasonable accuracy and gives some anatomical information such as presence of hydronephrosis • Useful in assessing renal parenchymal processes, which may mimic renal colic

  31. SHORTCOMINGS • It is virtually blind to upper and middle ureteral stones (sensitivity :19%) which are far more likely to be symptomatic than renal calculi. Distal ureteric calculi occasionally visualized though window of a fluid filled bladder. However, if a ureteral stone is visualized by ultrasound, is reliable (Specificity: 97%) • Frequent limitation in defining the level and nature of obstruction • Lack of functional information • Limited visualization of renal anatomy

  32. RETROGRADE PYELOGRAPHY • Indicated for patients in whom administration of intravenous contrast material is contraindicated or when the IVU or renal sonogram is inconclusive • Ureteral calculi typically produce a filling defect in the ureter and cause a discrepancy in the caliber of the ureter above and below the defect (dilated above, narrow below)

  33. CT SCAN • Advantages • Non contrast enhanced helical CT is fast and accurate and it readily identifies all stone types • in all locations • Quick, does not require intravenous contrast or bowel preparation • Its sensitivity (95-100%) and specificity (94-96%) suggests that it may definitely exclude stones in patients with colicky abdominal pain. • New signs such as renal enlargement, perinephric or periureteral inflammation or “stranding” and distension of the collecting system or ureter are sensitive indicators of degree of ureteral obstruction .

  34. Hounsfield density of calculi may be used to distinguish cystine and uric acid stones from calcium bearing stones and is capable of further subtyping calcium stones into calcium phosphate, calcium oxalate monohydrate and calcium oxalate dihydrate stones. • It is also useful in diagnosing non urolgic causes of abdominal pain, such as abdominal aortic aneurysms and cholelithiasis.

  35. LIMITATIONS • More expensive • Lack of functional information • Does not accurately delineate the anatomy of ureter and renal collecting system (detection of anomalies such as calyceal diverticulum or ureteral duplication is critical for proper preoperative planning). • Follow up of stone disease is usually done using plain films. In many instances, comparison of plain films with spiral CT is difficult in assessing stone movement or passage.

  36. MRI • MRI specifically used to visualise the urinary tract has been termed magnetic resonance (MR) urography. • MR sequencing using both half-fourier acquisition single-shot turbo spin-echo (HASTE) imaging and ultra-fast breath-hold sequences are technically adequate.

  37. ADVANTAGES OVER CT: • Effective in demonstrating urinary tract dilation and level of obstruction in 96% of cases. • Ability to identify perirenal fluid is of value in differentiating acute from chronic obstruction. • DISADVANTAGES: • Unable to visualise most stones clinically. • Not useful for characterising the composition of the stones. • Expensive.

  38. COMPLICATIONS OF UROLITHIASIS • Renal failure • Ureteral structure • Infection • Sepsis • Urine extravasation • Perinephric abscess • Xanthogranulomatous pyelonephritis HOW LONG CAN ONE WAIT BEFORE TREATING THE STONE? • In the absence of infection and with complete obstruction, detectable renal damage does not occur in previously normal kidneys until complete obstruction has been present for 4 weeks, so one can give the patient upto 4 weeks to pass the stone spontaneously.

  39. MANAGEMENT OF RENAL STONES Initial management of radiology confirmed stone CONFIRMED STONE RULE OUT EMERGENCY Urosepsis, anuria, rental failure Yes URGENT No UROLOGIC CONSULTATION CONSIDER HOSPITAL ADMISSION Refractory pain, refractory nausea Extremes of age, debilitated condition No SYMPTOMS AMENABLE TO MEDICAL MANAGEMENT Ureteral stone Renal stone or ureteral stone > 5mm REFERRED TO UROLOGIC CLINIC <5mm TRIAL OF CONSERVATIVE MANAGEMENT WEEKLY KUB RADIOGRAPHS Stone passes Stone fails to pass within 2 - 4 weeks

  40. EMERGENCY SITUATIONS • SEPSIS in conjunction with an obstructing stone – adequate drainage of the system must be established with all possible speed by means of percutaneous nephrostomy or retrograde ureteral stent insertion. • ANURIA & ACUTE RENAL FAILURE secondary to bilateral obstruction, or unilateral obstruction in a patient with a solitary functioning kidney – should be treated urgently. • Patients with REFRACTORY SYMPTOMS – should be treated by placing a retrograde ureteral stent or percutaneous nephrostomy tube as a temporizing measure.

  41. AMBULATORY MANAGEMENT • The corner stones of ambulatory management are adequate analgesia, timely urologic consultation and close follow-up. • Narcotics such as codeine, morphine, meperidine are effective in suppressing pain, but have side effects of dependence and disorientation. • NSAIDs such as Ketorolac, aspirin, diclofenac (Voveran) and ibuprofen are effective in managing pain of renal colic due to their combined anti inflammatory and spasmolytic effects.

  42. ANALGESIA • Unfortunately, the antiplatelet effects of NSAIDS are a contraindication to the use of ESWL, because of the increased risk of perinephric bleeding. • An effective approach to outpatient management is to use both an oral narcotic drug and an oral NSAID. • Patients are instructed not to take NSAIDs for 3 days before anticipated ESWL; also told to avoid aspirin for 7 days before the procedure.

  43. TREATMENT OPTIONS • CONSERVATIVE MANAGEMENT • The safest management of ureteral stones is spontaneous passage, provided there are no complicating factors. • The two major prognostic factors are stone size and location. PROBABILITY OF STONE PASSAGE

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