STONE DISEASE

( Brief Overview )
Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.),
Professor & HOD, Dept. of Urology, Sri Ramachandra Medical College & Research Institution Consultant Urologist & Renal Transplant Surgeon, Sri Ramachandra Hospital, Porur, Madras.

COMPARATIVE INCIDENCES OF FORMS OF URINARY LITHIASIS

Stone analysis in Percentage Form of Lithiasis Pure Calcium Oxalate Mixed Calcium Oxalate and Phosphate Magnesium Ammonium Phosphate (Struvite ) Uric Acid Cystine India 86.1 4.9 USA 33 34 Japan 17.4 50.8 UK 39.4 20.2

2.7

15

17.4

15.4

1.2 0.4

8.0 3.0

4.4 1.0

8.0 2.8

Cause of Stone Disease

Supersaturation of urine is the key to stone formation

Intermittent supersaturation - Dehydration

Crystal aggregation Anatomic Abnormailities PUJ , MSK

Bacterial Infection
Defects in transport of Calcium and Oxalate by Renal epithelia
E.Coli infection increases matrix content in urine . Proteus makes urine alkaline

Inhibitors & Promoters of Stone Formation in Urine

INHIBITORS
Inhibits crystal Growth Citrate complexes with Ca Magnesium complexes with oxalates Pyrphosphate - complexes with Ca Zinc Inhibits crystal Aggregation Glycosaminoglycans Nephrocalcin Tamm- Horsfall Protein

PROMOTERS
Bacterial Infection Matrix Anatomic Abnormalities PUJ obst., MSK Altered Ca and oxalate transport in renal epithelia Prolonged immobilisation Increased uric acid levels I.e taking increased purine subs promotes crystalisation of Ca and oxalate ?? Nanobacteria seen in 97% of renal stones

SOME DISEASES ASSOCIATED WITH HYPERCALCAEMIA & HYPERCALCIURIA

Hyperparathyroidism Sarcoidosis Multiple myeloma Hyperthyroidism Leukemia Lymphoma Myxedema Adrenal Insufficiency

Metastatic Malig. Neoplasm's

Vit. D Intoxication

TYPES OF KIDNEY / URETER STONES

OXALATE (CALCIUM OXALATE) PHOSPHATE

URIC ACID & URATE

CYSTINE

Uncommon Stones
XANTHINE STONES (Autosomal Recessive . Def of Xanthine Oxidase leading to Xanthinuria) DIHYDROXYADENINE STONE

( Def. of enzyme adenine phospo ribosyl transferase )

SlLICATE STONES Rare in humans ( excess intake of Antacid with Mg Trisilicate.
cattle due to ingestion of Sand ) Mostly in

MATRIX

- Infection by Proteus

- Radiolucent (all calculi have some amt ( 3%) of matrix but matrix calculus has 65% Matrix content in calculi)

Uncommon Stones
TRIAMTERENE Anti-hypertensive used with hydroclorothiazide spare Potassium.
Mostly found as a nucleus in Ca oxalate or uric acid calculus

Indinavir Stones - Drug to treat

AIDS (4 to13%)

Ephedrine or Guifenesin

Cough medicine - Radiolucent

Stones Chemical Constituents

Whewelite Calcium Oxalate Monohydrate CaC2O4-H2O

Weddelite - Calcium Oxalate dihydrate CaC2O4-2H2O

Brushite Calcium Hydrogen phosphate dihydrate CaHPO4 2H2O Whitlockite - TriCalcium Phosphate Ca2(PO4)2 Struvite Magnesium Ammonium hexahydrate MgNH4PO4-6H2O

DD of Radiolucent filling defect on IVU in Ureter or Kidney

Must Know Uric Acid Calculus Matrix Calculus Sloughed Papilla Blood Clots TCC Renal Cysts Vascular Lesions Know For Brownie Points
Xanthine Calculus Hydroxyadenine Calculus Ephederine Calculus Infection due to gas forming Org. Fungal Ball Tuberculoma Malacoplakia Hypertrophied Papilla Renal pseudo-tumour

OXALATE (CALCIUM OXALATE)

ALSO CALLED MULBERRY STONE COVERED WITH SHARP PROJECTIONS SHARP MAKES KIDNEY BLEED (HAEMATURIA) VERY HARD RADIO - OPAQUE
Under microscope looks like Hourglass or Dumbbell shape if monohydrate and Like an Envelope if Dihydrate

PHOSPHATE STONE
USUALLY CALCIUM PHOSPHATE SOMETIMES CALCIUM MAGNESIUM AMMONIUM PHOSPHATE OR TRIPLE PHOSPHATE

SMOOTH MINIMUM SYMPTOMS

DIRTY WHITE RADIO - OPAQUE
Calcium Phosphate also called Brushite appears like Needle shape under microscope

PHOSPHATE STONES
IN ALKALINE URINE ENLARGES RAPIDLY TAKE SHAPE OF CALYCES STAGHORN
Struvite can form Stag-horn and appear like coffin lid under microscope

CALCIUM PHOSPHATE STONES

Hyperparathyroidism Renal Tubular Acidosis Ca K P CO2

Medullary Sponge Kidney -

PTH Hormone Promotes renal production of 1-25-dihyroxycholecalciferol active Vit.D and also
increases absorption of Calcium and decreases Phosphorus absorption from Kidneys

URIC ACID & URATE STONE

HARD & SMOOTH MULTIPLE YELLOW OR RED-BROWN RADIO - LUCENT (USE ULTRASOUND)
Under microscope appear like irregular plates or rosettes
pKa of uric acid 5.75 at this pH 50% of uric acid insoluble. If pH falls further - uric acid more insoluble

CYSTINE STONE
AUTOSOMAL RECESIVE DISORDER USUALLY IN YOUNG GIRLS

DUE TO CYSTINURIA CYSTINE NOT ABSORBED BY TUBULES MULTIPLE SOFT OR HARD can form stag-horns PINK OR YELLOW

RADIO-OPAQUE
Under microscope appears like hexagonal or benezene ring ask for first morning sample

CYSTINE STONE - Management

High Fluid Intake and Alkalanise Urine dissolve most of the smaller cystine stones

D-Pencillamine or MPG (Mercaptopropionylglycine) binds to cystine that is soluble in urine

Side effects of Pencillamine restricts it use Allergic rashes, GI problems- Nausea, Vomiting, Diarrhoea

MPG better tolerated

Large obstructive stones Surgery required first

pKa of cystine is 8.3, hence alkalinisisation above pH7.5 helps to dissolve the stones Cyanide Nitroprusside Calorimeteric Test for detecting Cystinuria. If positive do amino acid chromatography

Surgical Conditions and Stone Disease

Regional ileitis and Ileal Bypass Surgery for eg Obesity can lead to increase oxalate absorption and stone ds ileostomies - In Chr. Diarrhoea with Bicabonate loss systemic acidosis and acidic urine increases risk of Uric Acid stones

HISTORY
A. IS PATIENT DRINKING ENOUGH ?

B. PROFESSION
C. ENQUIRE ABOUT UTI STONES

D. FAMILY HISTORY
E. LONG ILLNESS BEDRIDDEN STONES

MANAGEMENT OF STONES
HISTORY : A. FIND OUT IF DRINKING ENOUGH LIQUIDS (NOT DRINKING ENOUGH IMPORTANT CAUSE OF STONE FORMATION & GROWTH)
Urinary supersaturation of salts in concentrated urine Atleast drink 3 lits to avoid stone formation

HISTORY (Cont...)
B. ASK ABOUT THEIR PROFESSION DEHYDRATION STONES CAN FORM e.g. MARATHON NEAR A FURNACE,

BRICK - LAYER, LABOURERS & WEAVERS

TRUCK & BUS DRIVERS

HISTORY (Cont...)

C. ENQUIRE ABOUT UTI STONES D. FAMILY HISTORY E. LONG ILLNESS BEDRIDDEN STONES
Zero Gravity state astronauts on long space flights more prone to stones

CLINICAL FEATURES
1. PAIN IN 75 % OF THE CASES RENAL COLIC IF SEVERE AND ACUTE

A) KIDNEY STONE
FIXED PAIN IN THE LOIN B) URETERIC STONE PAIN RADIATES LOIN TO GROIN
Both Stomach & Kidney supplied by celiac ganglion hence Nausea & vomiting common in renal colic

CLINICAL FEATURES (Contd....)

2) HAEMATURIA CAN BE FRANK OR ONLY FOUND ON DIP - STICK OR LAB.

3) PYURIA - IF INFECTION CAN HAVE PUS IN URINE

ON EXAMINATION
1. ACUTE PRESENTATION ABDOMEN TENSE AND RIGID TENDERNESS PRESENT IN THE LOIN 2. IN ROUTINE PRESENTATION NO FINDINGS IN ABDOMEN

INVESTIGATIONS
1. FULL BLOOD COUNT TO CHECK FOR ANAEMIA IF GOING FOR SURGERY 2. SERUM ELECTROLYTES PLUS UREA / CREATININE / CALCIUM / URIC ACID / PHOSPHATE

INVESTIGATIONS (Cont...)
3. 24-HOURS URINE FOR ELECTROLYTES (Only if recurrent stone former) CALCIUM / OXALATE / URIC ACID / CYSTINE / CITRATE

INVESTIGATIONS (Cont...)

4. PLAIN KUB X-RAY OF ABDOMEN (Mandatory) 5. IVU OR IVP (INTRA VENOUS UROGRAM) 6. ULTRASOUND (Mandatory)

INVESTIGATIONS
IVU OR IVP (INTRA VENOUS UROGRAM) Not Mandatory 1in 40,000 patients die due to anaphylactic reaction to contrast Useful for radio-lucent stones & to detect Congenital Anomalies in Urinary tracts

INVESTIGATIONS (Cont...)
7. CT
TO LOOK AT UNUSUAL ANATOMY OF THE KIDNEY

To differentiate cause of acute colic stone or anuria Suspected due to stone disease 8. DMSA OR DTPA OR MAG3 RENOGRAM - TO STUDY FUNCTION OF EACH KIDNEY.

Bilateral Ureteric Calculus in a patient presenting with Anuria

Helical or Spiral CT provides 3D reconstruction. Helical refers to path the X ray follows on Gantry. These are rapidly performed and do not require contrast agents for reconstruction.

MANAGEMENT OF UROLITHIASIS
Non-invasive approach to urinary calculasHALLMARK of last 20 yrs. Lithotripters 1.Extra Corporeal Shock wave 2.Intra Corporeal Better fiber optics Miniturisation of Telescopes Accessories - Innovative variety

Modern Management of Urolithiasis

ESWL Ureterorenoscopy Percutaneous Nephrolithotomy Laparoscopic Approach to stones

Open Ureterolithotomy, Pyelolithotomy or Nephropyelolithotomy is required in less than 1 to 2% of modern stone management

TREATMENT (IDEALLY)

MAJORITY : 80 TO 85 % of all stones can be treated by EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL) MINORITY : 15 TO 20 % SHOULD NEED MINIMALLY INVASIVE SURGERY (PCNL / URETEROSCOPY)

(LESS THAN 1 % SHOULD NEED OPEN SURGERY)

EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)

SHOCK WAVES GENERATED UNDER WATER CAN

TRAVEL THROUGH BODY WITHOUT ANY APPRECIABLE LOSS OF ENERGY. WHEN THEY ENCOUNTER STONES THE CHANGES IN DENSITY CAUSES ENERGY TO BE ABSORBED AND REFLECTED BY THE STONE & THIS RESULTS IN FRAGMENTATION OF THE STONES.

ESWL For Urinary Tract Calculus

ESWL- FOUR MAIN ELEMENTS

1. 2. 3. 4. ENERGY SOURCE FOCUSING DEVICE COUPLING DEVICE LOCALIZATION DEVICE

ESWL
Absolute Contra-indicationPregnancy Relative Contra-Indications for ESWL

Renal Colic Urinary obstruction Infection Declining Renal Function Significant Hematuria

COUPLING DEVICE
WATER BATH WATER FILLED CUSHION (KEEP PATIENTS DRY)

ESWL-HISTORY
1963-EXPERIMENTS WITH SHORT WAVES IN W.GERMANY BY PHYSICISTS AT DONIER SYSTEMS LTD 1980-DORNIER HUMAN MODEL ( HM-3) LITHOTRIPTER ARRIVED ON MARKET (STILL GOLD STANDARD WHEN COMPARING RESULTS WITH NEW MEASUREMENTS

ESWL & STAGHORNS

Dornier HM-3 Monotherapy for STAGSHORNS 30% Stone Free Rate (In Dilated Collecting System ) PCNL has higher overall Success Combination of PCNL & ESWL can give a stone free rates of 90% For ALL STONES IN THE KIDNEY

COMPRESSION-TENSILE WAVE CAUSES:

Implosion Rather than Explosion

ESWL & URETERIC CALCULI

For fragmentation fluid medium around stone necessary If stones impacted fragmentation may not occur PUSH & BANG-success Marginally HIGHER THAN in situ ESWL Trial of in situ ESWL first choice In situ ESWL FAILS- Rescue procedure

ESWL COMPLICATIONS
Haematuria is quite common ( short term antibiotics Recommended ) Incomplete stone Fragmentation & Obstruction Stienstrasse ( stone street ) usually due to a large Leading fragment ( Stents Recommended prior to ESWL for Calculi > 1.5 cm )

DESIGN BASIC LITHOTRIPSY

Renal Lithiasis Blood Pressure Study ( Patients treated 1984-1986 Dallus Study)
First Follow Up Second Follow Up 1988 1990 No.Pts Annualized Rate No.Pts Annualized Rate of Hypertension of Hypertension ESWL 771 2.5% 590 2.1% non-ESWL 195 3.8% 155 1.6% Total 966 745

Basic Principles of SHOCK WAVE Lithotripsy

FRAGMENTATION BY SHOCK WAVES

ON COLLISION OF SHOCK WAVES WITH CALCULI ON FRONT SURFACE COMPRESIVE FORCES ON BACK SURFACE OF THE STONEREFLECTION OF COMPRESSION PULSE CREATES NEGATIVE OR TENSILE WAVE THAT TRAVEL BACK WARD THROUGH CALCULI ONCE TENSILE FORCE EXCEEDS COHESIVE STRENGTH OF CALCULI- FRAGMENTATION OCCURS

ESWL SPARK GAP/ EHL

Electro-hydraulic Generator Located at Base of Water Bath Produces Shock wave by Electric Spark Gap of 15,000 to 25,000 Volts Lasting 1 Sec High Voltage Spark Discharge Rapidlyevaporates Water & Generators A Shock Wave by expanding Sarrounding Liquid

Mechanism of Stone Fragmentation by ESWL

On Front Surface Compresive or positive Forces On Back Surface Of The StoneReflection Of Compression Pulse Creates Negative Or Tensile Wave That Travel Back Ward Through Calculi Once Tensile Force Exceeds Cohesive Strength Of Calculi- Fragmentation Occurs Cavitation Small air bubbles

Steinstrasse ( or Stone Street) Post ESWL

Diet & Fluid Advice

High Fluid Intake

Restrict Salt (Na)

Oxalate Restrict Avoid high intake of Purine food

Increased citrus fruits may help

If hypercalciuria restrict Ca intake
Role of Potassium Citrate in preventing Cal Oxalate stone ds KCit lowers urinary calcium whereas Na Citrate does not lower Calcium due to Sodium load

LIQUIDS
Moderate Amounts : Apple Juice Beer Coffee High Amounts : Cocoa Fresh Tea

Cola
FOODS : Almonds, Asparagus, Cashew Nuts, Currants, Greens,

Plums, Raspberries, Spinach

HIPPOCRATIC OATH :

I Will not cut, even for the stone, but leave such procedures for the practitioners of the craft