Stone formation

INCIDENCE
- One of the most common diseases of the UT. 3rd after UTI, prostate diseases.
- General incidence 1- 5%
- Age: 3rd – 4th decade. An initial stone attack after age 50 years is relatively uncommon
- Sex: more in males (? Test →↑ end. Ox. Production). due to higher crystal inhibitors in
females (citrates).

Theories of stone Formation

supersaturation urine becomes oversaturated with a type of solute normally dissolved in
the urine which then comes out of solution…. (crystallization forming crystals) that then
aggregate and form stones.
Formation of a calcified plaque in the sub-epithelium of the renal papillae (known as a
Randall plaque): that act as a nidus for stone formation.
Deficiency of urine crystallization inhibitors: citrate

General Predisposing factors

• Renal factors
– Urine stasis U.T. obstruction: PUJO, stricture ureter, BPH
– UTI
• Environmental factors
– Climate: temperature and humidity→ fluid loss→  urine concentration
– Diet: animal proteins, oxalate
– A positive family history of urolithiasis is associated with an increased risk of
urinary stone disease
– Sedentary life
TYPES OF STONES
Classification
According to stone location
o Renal stone
o Ureteral stones
o Bladder stones
o Urethral stones

According to stone type

❖ Calcium stones:80 %
o Calcium oxalate monohydrate.
o Calcium oxalate dihydrate.
❖ Struvite stones: 10%
❖ Uric acid stones:< 5%
❖ Cystine stones:1%

1- CALCIUM STONES (MOST COMMON) (80%)

o Calcium oxalate monohydrate stones: dark brown/black in color.
o Radiopaque on radiology
AETIOLOGY
• Hypercalcemia: normal 9-11 mg/dl
– Hyperparathyroidism (primary and tertiary)
• Hypercalciuria: urinary calcium excretion of more than 4 mg/kg/d is the most common
metabolic abnormality: 3 forms
– Absorptive: related to increased intestinal absorption of calcium (associated with
excess dietary calcium and/or overactive calcium absorption mechanisms).
– Resorptive: related to excess resorption of calcium from bone (as in
hyperparathyroidism and immobilization).
– Renal-leak hypercalciuria: related to impaired tubular absorption of calcium.
• Hyperoxaluria: due to malabsorption disorders
2- Struvite stone (10%)
➢ magnesium, ammonium, phosphate (MAP)
Risk factors for formation
❖ Occurs due to Infection with urea splitting organism: Proteus, Pseudomonas,
Klebsiella, Staphylococci, and Mycoplasma
❖ These organisms produce urase enzyme → split urea → ammonium → alkaline
urinary pH → MAP crystals precipitate (when ph. 7.2)
❖ Form in alkaline pH
❖ Grossly: Stones are usually stag horn, yellow/white in color, smooth, laminated

3- Uric acid stones (5%)

The main Risk factors for formation
➢ Hyperuricosuria as in
– gout, myeloproliferative diseases

• Form in acidic urine (a urinary pH consistently <5.5

• Grossly: Stones are yellowish,
• Radiolucent.

4- Cystine Stones (1%)

Risk factors for formation
▪ Secondary to an inborn error of metabolism leading to cystinurea
o Cystine lithiasis is the only clinical manifestation of this defect.
▪ Forms in acidic pH
▪ The solubility of cystine is pH-dependent and the solubility increases as the pH
increases.
▪ Very high recurrence rate.
 5- Rare types of stones
• Xanthine:
– Occurs due to a congenital deficiency of xanthine oxidase enzyme.
– Form in acidic urine
– The stones are radiolucent and are tannish yellow in color.
• Indinavir:
– is a protease inhibitor used in treating patients with AIDS and results in formation
of radiolucent stones in up to 6% of patients.
• Rare: Silicate stones.

Renal stones
Clinical presentation
➢ Asymptomatic
➢ Pain:
Form: Renal colic or dull ache
Severity: varies according to the site , size of the stone, degree and acuity of
obstruction
- Severe agonizing pain: in acutely obstructed kidney (as in Ureteropelvic stone)
- Occasional mild pain: Small non-obstructing calyceal stones
- Painless: Stag horn stones are often relatively asymptomatic and painless
Site: loin
➢ Hematuria: Gross or microscopic
➢ Recurrent U.T.I.
➢ Nausea and Vomiting during the colicy attack: due to Close anatomical proximity and
Shared innervations
➢ Picture of complications
Examination: costovertebral angle tenderness, palpable kidney
Picture of complications
❖ Infection
o Pyelonephritis:
▪ Acute toxemia, high grade fever, loin pain and tenderness
o Pyonephrosis: suppurative infection& destruction of the renal parenchyma, PCS
and perinephric fat.
▪ Chronic toxemia with pallor, low grade fever, asymptomatic bacteriuria.
▪ Kidney is palpable, mildly tender, with ill-defined border.
o Infected hydronephrosis
o Bacterial infection in an obstructed kidney with pus in the collecting system
o a relative medical emergency necessitating drainage with PCN
o fever, tachycardia, flushing.
o Palpable severely tender kidney.
❖ Deterioration of the renal function
❖ anuria: if obstruction of the O.F. kidney or bilateral obstruction
❖ Metaplasia (squamous metaplasia) squamous cell carcinoma

Differential diagnosis
1. Skin / subcutaneous tissues ---- Herpes
2. Muscles – spasm
3. Lungs - pleurisy
4. Liver – hepatitis, abscess,
5. GB – cholecystitis
flank pain, stone or musculoskeletal?
❖ Unilateral
❖ Unaffected by position or activity
❖ Radiates anteriorly, testicle
❖ often bilateral, little lower
❖ Worse with activity, end of the day
❖ Can radiate to buttocks or down thigh
Investigation
A. Laboratory investigation
Metabolic work up for recurrent stone formers
1- urine analysis
2- blood tests
3- stone analysis
B. Imaging
1. Abdominal US
2. M.S.CT.
3. PUT
4. IVU
C. Assessment of renal function

A- Laboratory Investigation:
1- urine analysis
❖ Physical:
o Volume: around1500 ml/day
o Color: amber yellow
▪ red→ gross hematuria,
o Aspect: clear
▪ turbid urine
o Specific gravity: 1015-1025
▪ Low fixed at 1010 ➔ renal impairment
o pH: 5.8-6.2
▪ alkaline → infection stone
▪ Acidic ➔ uric acid stones, cystine stone
 ❖ Chemical examination:
o Cystine, protein, calcium, oxalate, uric acid
❖ Microscopic
o R.B.Cs, pus cells
❖ Bacteriologic examination
o Urea splitting organisms
o Urine culture and sensitivity

2- Blood tests
➢ R. F. tests S creatinine: 0.6~1.2 mg/dl
➢ uric acid: up to 6 mg/dl
➢ Serum calcium: 9~11 mg/dl.
➢ If serum calcium is high ➔ Exclude hyperparathyroidism
o Repeated assessment of serum calcium level
o Measurement of PTH (Parathormone)

3- Identification of the stone type

• Chemical analysis Obsolete.

• Infra-red spectroscopic analysis

B- Imaging:
1- U.S
❖ Stone
o Rapid bed side test
o Diagnose both radiolucent and radiopaque stone
❖ U.T
o Assess degree of obstruction and the cortical thickness
o Internal echoes in case of obstruction with infection
 2- M.S.C.T
❖ Noncontrast CT scans are now the 1st modality of choice
❖ Advantages
o Uremic patients
o No contrast.
o No bowel prep
o can see noncalcified stones (radiolucent stones)
o DD renal and extra-renal radio-opaque shadows
3- PUT
Detect radio-opaque stones: 90% radio-opaque
Define criteria of the stone
site: calyceal, pelvic
Size: small, large (exact dimensions, stone burden)
Number: single, multiple, enumerable
Shape: rounded, triangular, branched, staghorn
May help to define the composition of the stone (through density of radiopacity)
o Calcium stones: Densely radio-opaque
o Infection stones: slightly opaque, laminated.
o Cystine: faintly opaque.
o Uric acid: radiolucent.
Limitation of PUT
• Contraindicated during pregnancy
• Exposure to radiation
• Need bowel preparation
• Can miss faint stones over bone
• 10% → radiolucent
• No idea about U.T.
D.D.
• Have to exclude other radiopaque shadow in PUT:
– Gall bladder stone (US, A right lateral view is essential when a radio-opaque
shadow(s) is shown in the right renal area. A renal calculus overlies the vertebral
bodies whereas gallstones are far anterior)

4- IVU
❖ Diagnose associated anomalies: as double PCS or malrotated kidney, PUJO.
❖ Diagnose radiolucent stones
❖ define exact position of the stone
❖ Reveal degree of obstruction
❖ Confirm distal patency
❖ Function of the other kidney
❖ Not to be done in patients with (contraindications)
o renal colic
o Uremia (creatinine > 2 mg)
o Dye HS.
o Pregnancy.
C. Assessment of renal function
• In cases of advanced hydronephrosis and non-secreting kidney
• Sonar: renal cortex>3mm
• RIS: DMSA scan
• Nephrostomy:
– > 300ml/day, concentrated (urine specific gravity > 1015 -1025), non-infected
urine.
Management of renal stones

1- Medical treatment
– Treatment of acute renal colic
– Treatment to prevent stone recurrence
2- ESWL
3- PCNL
4- RIRS
5- Open surgery (pyelolithotomy or pyelonephrolithotomy)

Medical Treatment
A - Treatment of acute renal colic
1- Analgesics:
a. NSAIDS
b. Meperidine (Pethidine): 50-100 mg (IM injection).
c. Morphine: 5-10 mg (IM).
2- Antispasmodics
What is the role of I.V. fluids?
– only in patients with repeated vomiting to restore euvolemic status but avoid
overhydration.
– Increase fluid intake allow more PCS distention and more pain

Indication for hospitalization and intervention

1- Intractable pain Persistent renal colic Impacted stone→
– anti-edematous (antihistaminic)
– Antibiotics
– If failed…. intervention
2- Infection, fever…… PCN
3-Solitary kidney or bilateral obstruction with uremia……. PCN or ureteroscopy and DJ stent

B - Treatment to prevent stone recurrence

• Recurrence rate is 35% at 5 years
• Who are more liable for recurrence:
– Patients presented with multiple stones,
– personal or family history of previous stone formation
– presentation with stones at a younger age,
– residual stones after treatment.

• Medical therapy is generally effective at delaying (but perhaps not completely stopping)
the tendency for stone formation.

General advice:
• 1- High Fluid Intake.
• 2- Restrict Salt (Na).
• 3- Oxalate Restrict (Spinach , Chocolate, tea ,coffee Strawberries, coca cola)
• 4- Avoid high intake of Purine food (red meat).
• 5- Increased citrus fruits (best is lemonade).
Specific advices
Calcium stone:
o Thiazides Increase tubular calcium reabsorption → decrease calcium in urine
o Side effects: extra-cellular volume depression. So, it is not used for long run.
o Citrate. Mg citrate: prevents crystallization and stone formation.
o Treatment of hyperparathyroidism
Uric acid→ alkalinization of urine + allopurinol if the uric acid in blood is raised
Cystine: alkalinization of urine + medications that form soluble complex with cystine
Penicillamine or Mercaptopropionylglycine (Thiola): which It is better tolerated than
penicillamine.
Struvite stones: acidification with citric acid + Antibiotics: according to Culture and
specificity to maintain sterile urine + Removal of F.B.: catheters, and all stone fragments.

ESWL
Extra-corporeal Shock Wave Lithotripsy
Introduced by Chaussy in 1980
• Stone localization Device (fluoroscopy, sonar)
• Coupling mechanism: Water cushion
• Energy source: Electrohydraulic, piezoelectric, electromagnetic

Mechanism of stone fragmentation by ESWL

• ON COLLISION OF “SHOCK WAVES” WITH CALCULI-
A- On front surface ……. Compressive forces
B- On back surface of the stone…… reflection of compression pulse creates negative
tensile wave that travel backward through the calculi
• Once the tensile force exceeds the cohesive strength of the calculi fragmentation occurs.
Indications
– Renal stones
• < 2cm
• No distal obstruction
– Upper ureteral stone

Advantages
➢ Day surgery return to work in 24 hours
➢ Duration of about 1 hour
➢ Sedation, occasional GA (children)
Contra-indications
o Pregnancy
o Bleeding diathesis
o Distal obstruction
o Uncontrolled UTI
o Severe obesity
o Very hard stone (> 1000 HU on NCT)

Outcome
Success rate
➢ Renal pelvis: 90%
➢ Middle & upper calyceal: 80%
➢ Lower calyceal: 70%
It depends on
1- Infundipulo-pelvic angle ≥ 90º
2- Infundipular length ≤ 3 cm
3- Infundipular width ≥ 5 mm.
Complications
– Pain
– Hematuria
– Hematoma (more with aspirin taking patients):
• at the entry site
• Peri-renal
– Inadequate fragmentation or failure.
– Retained stone fragments (Stein Strasse)
Treatment:
1- Observation.
2- PCN.
3- Ureteroscopy and DJ stent

PCNL
• Indications
– Size: >2 cm
– stones resistant to ESWL ( > 1000 HU)
– Lower pole calyceal stones not ideal for ESWL
• Contraindications
The only contraindication is Irreversible coagulopathy
Technique:
• Insertion of ureteric catheter.
• Prone positioning.
• Needle puncture (Sonar or Fluoroscopy guided) and guide wire insertion
• Dilatation of the tract and amplatz sheath insertion to preserve the tract.
• Nephroscopy and extraction of the stone
RIRS
1- Coagulopathy
Patients who must remain on systemic anticoagulation.
➢ severe coronary artery disease,
➢ cerebrovascular disease
➢ prosthetic mitral valves .
2- Morbid Obesity
- PCNL ……… Difficult positioning + anesthesia and long tract.
- ESWL……Too large for many SWL machines + difficult focus (SSD > 10 CM) .
3- Skeletal anomalies
- Significant scoliosis or contractures or kyphoscoliosis.
- PCNL …Difficult positioning, anesthesia and sometimes there is no adequate distance
between the ribs and the iliac crest.
- ESWL…… Difficulties in positioning, targeting and coupling.

Laparoscopy or Open surgery

❖ open surgery should be avoided unless else Fails or is high likely to fail.
Indications: Few indications in the era of minimally invasive therapy
– Lack of experience
– Lack of facilities
– Need to correct associated pathology
• PUJO with aberrant vessels
– Stag horn stone
Aetiology
• Primary ureteral stones :
– the ureteral stones is primarily formed inside the ureter which occurs in the cases
of chronic ureteral obstruction and urine stasis.
– Usually, multiple, rounded
• Secondary ureteral stones :
– ureteral stones are secondary to renal stones that migrate downwards to the
ureter
– Single , date shaped
Clinical Picture
• Renal colic : the most common symptom
• Pathophysiology
– Stone migration leading to irritation of the ureter and strong peristalsis.
– Renal distention due to obstruction of the PCS.
• Referral:
– upper ureteral stones➔ posterior radiating to the testicle in male and labia
majora and groin in female
– Middle ureteral stones ➔ localized
– Lower ureteral stone associated with lower urinary symptoms
• Associated symptoms:
– Urologic: Hematuria, B.M
– GIT: nausea, vomiting
Picture of complications
• Infection
Infected hydronephrosis
• Deterioration of the renal function
• anuria : if obstruction of the O.F. kidney or bilateral pathology
Differential diagnosis
➢ Appendicitis,
➢ Salpingitis, ectopic pregnancy ,Ovarian cyst / torsion

Investigation
A- Laboratory investigation
Metabolic work up for recurrent stone formers
1- urine analysis
2- blood tests
3- stone analysis
B- Imaging investigation
1- abdominal US
2- PUT
3- IVU
4- M.S.CT.

U.S.
• Rapid bedside test
It helps to show :
❖ The degree of back pressure on the kidneys.
❖ The cortical thickness.
❖ The other kidney.
❖ It can show the ureteral stone in the ureter if it is dilated or the stone in the intramural
ureter.
PUT
• It can detect 90% of the stones which are radio-opaque and location.
• Ovoid or date shaped at the anatomical site of the ureter.
• Distal obstruction is suspected if
Multiplicity
Huge ureteric stone
Limitation of PUT
▪ Contraindicated during pregnacy
▪ Need bowel preperation
▪ Can miss faint stones over bone
▪ 10% → radiolucent
▪ No idea about U.T.
DD of radioopaque shadows in the course of the ureter
➢ Phleboli,
➢ Calcified lymph nodes,
➢ Fecolith,
➢ Calcified ovaries or fibroids,
➢ Foreign bodies

IVU
• It evaluates :
– The renal function.
– Degree of obstruction.
– Presence or absence of ureteral stricture.
– The state of the contra-lateral kidney and ureter.
• Not to be done in patient s with (contraindications)
– renal colic
– Uremia(creatinine > 2 mg)
– Dye hypersensitivity
M.S.C.T.
Noncontrast CT scans are now the modality of choice because the following
Advantages

• Uremic patients
• No contrast
• no bowel prep
• can see (faint , radiolucent , against the bone stones)
• DD ureteral from extra ureteral radio-opaque shadows

Ureteral stone management

1- Medical treatment
– Treatment of acute renal colic
– Treatment in between the attacks.
– Treatment to prevent stone recurrence
2- Ureteroscopy OR FURS
3- ESWL
4- PCNL
5- Laparoscopy
6-Open surgery (pyelolithotomy or pyelonephrolithotomy)
Medical Treatment
A - Treatment of acute renal colic
• Analgesics:
– NSAIDS
– Meperidine (Pethidine): 50-100 mg (IM injection).
– Morphine: 5-10 mg (IM).
• Antispasmodics
The rule of fluid intake
• Increased fluid intake → ureteral distension ,less effective peristalsis (No coaptation of
the ureteral walls )→ will not help stone spontaneous passage,
b- MET (Medical Expulsive Therapy) in between the attacks
– NSAIDs relaxation of ureteral smooth muscle and decrease ureteral edema ……
Diclofenac 50 mg twice daily
– Alpha 1-Adrenergic receptor blockers (Tamsulosin, etc.) Alpha 1 stimulation produces
ureteral contraction
Indications
Stones
single
small stone < 6mm
Smooth
UT
Distal patency
Site
The overall passage rate stones is:
1- Proximal ureteral stones: 25%.
2- Mid-ureteral stones: 45%.
3- Distal ureteral stones: 70%.
Patient
can withstand pain
contraindications
• Stones
1. multiple stone
2. Large
3. Irregular

• UT
1. infection , fever
2. obstruction of O.F. kid or bilateral renal obstruction
3. failure of progress for 4 weeks (or persistent colic)

• Patient
1- patient preference
3- professional job
C- PREVENTION THERAPY IN BETWEEN THE ATTACK

Ureteral Stone Management

Ureteroscopy
• Indication : for upper , middle , lower ureteral stones.
• Steps
1. Identification of ureteric orifice
2. Guide wire insertion
3. Dilatation of the ureters
4. Ureteroscopy
5. Extraction of the stone
If small→ extracted by Dormia basket.
If large → Disintegration ± extraction of the particles by
one of the following disintegrators :
• Ultrasonic .
• Pneumatic.
• Laser.
• Electro-hydraulic.
6. Ureteric stenting
ESWL
➢ upper third ureter either in situ or after push back to the kidney and ureteral stenting
➢ lower third ureter in male (not in female) but the ureteroscopy is superior in this site
➢ NOT in the middle third as the pelvic bone gave no window for shock wave application

PCNL For upper ureteral stones

LAPAROSCOPY For upper ureteral stone
Open surgery (ureterolithotomy)
• Indications:
– Large stone
– Associated pathology: stricture ureter
• Technique: ureterolithotomy
– Upper ureter→ Anterior Morrison incision
– Middle ureter → Abbernathy incision
– Lower ureter → suprapubic midline incision

Bladder stone
Etiology
Pre-disposing factors:
• Urine stasis
– Infra-vesical obstruction.
– Neurogenic bladder.
– Bladder diverticulum
• F.B.: catheters, D.J
Clinical presentations
Cystitis syndrome
o Increased frequency , urgency
o Burning micturition
o Changed in urine: Haematuria
o Symptoms are usually diurnal
Referred Pain at the tip of the penis.
Difficult urination
o Interrupted stream
o Acute retention: if the stone impacts at the bladder neck.
In children:
o usually cries during micturition
o do pinching of the glans at micturition.
Imaging Investigations:
1- U.S.
– detects both radio-opaque and lucent stones.
– can diagnose other pathologies in the bladder as
diverticulum, tumor
2- PUT
• diagnose all radio-opaque bladder stones.
• detect other stones in the kidneys or ureters
• Findings
– Number: single or multiple
– size
– Shape: rounded, dumble-shaped.
3-IVU
delineate associated pathology as bladder diverticulum, BPH, small sized bladder,
bladder filling defect

Stone bladder treatment

Open surgery (cystolithotomy) Endoscopic
1- Large stone >3cm 1- Lithotripsy and stone extraction
2- Associated pathology
Diverticulum
BPH (> 80 gm)
 urethral stone
• Usually a migrating stone ureter that becomes impacted in the urethra
• Clinical Presentation. :
– marked difficulty
– Acute retention
– Usually proceeded by a history of renal colic
Clinical examination palpation of the stone+ picture of acute retention
prostatic urethera
bulbar urethera
penile urethera
fossa navicularis

Investigations
1- US … full bladder
2- PUT
Site:
– Post. Urethra: behind symphysis pubis or in between pubic arch
– Anterior urethra

Stone urethra treatment

• Stone post-urethra→ push back to the bladder then manage as a stone bladder
(endoscopic lithotripsy and extraction)
• Stone anterior urethra→ endoscopic disintegration in situ.
• Stone in the fossa navicularis → ventral meatotomy