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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.

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STONE DISEASE

( Brief Overview )

Dr. Sunil Shroff, MS, FRCS (UK), D.Urol (Lond.),

Professor & HOD, Dept. of Urology,Sri Ramachandra Medical College & Research InstitutionConsultant Urologist & Renal Transplant Surgeon,Sri Ramachandra Hospital, Porur, Madras.


Comparative incidences of forms of urinary lithiasis
COMPARATIVE INCIDENCES OF FORMS OF URINARY LITHIASIS

Stone analysis in Percentage

Form of Lithiasis India USA Japan UK

Pure Calcium Oxalate 86.1 33 17.4 39.4

Mixed Calcium Oxalate and 4.9 34 50.8 20.2Phosphate

Magnesium Ammonium 2.7 15 17.4 15.4Phosphate (Struvite )

Uric Acid 1.2 8.0 4.4 8.0

Cystine 0.4 3.0 1.0 2.8


Cause of stone disease
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

Inhibitors & Promoters of Stone Formation in Urine


Some diseases associated with hypercalcaemia hypercalciuria
SOME DISEASES ASSOCIATED WITH HYPERCALCAEMIA & HYPERCALCIURIA

Hyperparathyroidism Leukemia

Sarcoidosis Lymphoma

Multiple myeloma Myxedema

Hyperthyroidism Adrenal Insufficiency

Metastatic Malig. Neoplasm's Vit. D Intoxication


Types of kidney ureter stones
TYPES OF KIDNEY / URETER STONES HYPERCALCIURIA

  • OXALATE (CALCIUM OXALATE)

  • PHOSPHATE

  • URIC ACID & URATE

  • CYSTINE


Uncommon stones
Uncommon Stones HYPERCALCIURIA

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. Mostly in cattle due to ingestion of Sand )

MATRIX

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


Uncommon stones1
Uncommon Stones HYPERCALCIURIA

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
Stones – Chemical Constituents HYPERCALCIURIA

  • 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 HYPERCALCIURIA

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

DD of Radiolucent filling defect on IVU in Ureter or Kidney


Oxalate calcium oxalate
OXALATE (CALCIUM OXALATE) HYPERCALCIURIA

  • 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
PHOSPHATE STONE HYPERCALCIURIA

  • 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
PHOSPHATE STONES HYPERCALCIURIA

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
CALCIUM PHOSPHATE STONES HYPERCALCIURIA

  • Hyperparathyroidism Ca P

  • Renal Tubular Acidosis K 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
URIC ACID & URATE STONE HYPERCALCIURIA

  • 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
CYSTINE STONE HYPERCALCIURIA

  • 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
CYSTINE STONE - Management HYPERCALCIURIA

  • 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
Surgical Conditions and Stone Disease HYPERCALCIURIA

  • 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
HISTORY HYPERCALCIURIA

A. IS PATIENT DRINKING ENOUGH ?

B. PROFESSION

C. ENQUIRE ABOUT UTI ® STONES

D. FAMILY HISTORY

E. LONG ILLNESS ® BEDRIDDEN ® STONES


Management of stones
MANAGEMENT OF STONES HYPERCALCIURIA

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
HISTORY HYPERCALCIURIA(Cont...)

B. ASK ABOUT THEIR PROFESSIONDEHYDRATION ® STONES CAN FORM e.g.

  • MARATHON NEAR A FURNACE,

  • BRICK - LAYER, LABOURERS & WEAVERS

  • TRUCK & BUS DRIVERS


History cont1
HISTORY HYPERCALCIURIA(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
CLINICAL FEATURES HYPERCALCIURIA

1.PAIN IN 75 % OF THE CASES “RENAL COLIC” IF SEVERE AND ACUTE

A) KIDNEY STONE FIXED PAIN IN THE LOIN

B) URETERIC STONEPAIN RADIATES ® LOIN TO GROIN

Both Stomach & Kidney supplied by celiac ganglion hence Nausea & vomiting common in renal colic


Clinical features contd
CLINICAL FEATURES HYPERCALCIURIA(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
ON EXAMINATION HYPERCALCIURIA

1. ACUTE PRESENTATION

  • ABDOMEN TENSE AND RIGID

  • TENDERNESS PRESENT IN THE LOIN

    2. IN ROUTINE PRESENTATION

  • NO FINDINGS IN ABDOMEN


Investigations
INVESTIGATIONS HYPERCALCIURIA

1. FULL BLOOD COUNT TO CHECK FOR ANAEMIA IF GOING FOR SURGERY

2. SERUM ELECTROLYTES PLUS UREA / CREATININE / CALCIUM / URIC ACID / PHOSPHATE


Investigations cont
INVESTIGATIONS HYPERCALCIURIA(Cont...)

3. 24-HOURS URINE FOR ELECTROLYTES (Only if recurrent stone former)

CALCIUM / OXALATE / URIC ACID / CYSTINE / CITRATE


Investigations cont1
INVESTIGATIONS HYPERCALCIURIA(Cont...)

4. PLAIN KUB X-RAY OF ABDOMEN (Mandatory)

5. IVU OR IVP (INTRA VENOUS UROGRAM)

6. ULTRASOUND (Mandatory)


Investigations1
INVESTIGATIONS HYPERCALCIURIA

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 cont2
INVESTIGATIONS HYPERCALCIURIA(Cont...)

  • 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
MANAGEMENT OF UROLITHIASIS Anuria

  • Non-invasive approach to urinary calculas-HALLMARK 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
Modern Management of Urolithiasis Anuria

  • 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
TREATMENT Anuria (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
EXTRA - CORPOREAL SHOCK WAVE LITHOTRIPSY Anuria (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 four main elements
ESWL- FOUR MAIN ELEMENTS Anuria

  • ENERGY SOURCE

  • FOCUSING DEVICE

  • COUPLING DEVICE

  • LOCALIZATION DEVICE


ESWL Anuria

Absolute Contra-indication-

Pregnancy

Relative Contra-Indications for ESWL –

  • Renal Colic

  • Urinary obstruction

  • Infection

  • Declining Renal Function

  • Significant Hematuria


Coupling device
COUPLING DEVICE Anuria

“WATER BATH”

“WATER FILLED CUSHION”

(KEEP PATIENT’S DRY)


Eswl history
ESWL-HISTORY Anuria

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
ESWL & STAGHORNS Anuria

  • 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
COMPRESSION-TENSILE WAVE CAUSES: Anuria

“Implosion” Rather than “Explosion”


Eswl ureteric calculi
ESWL & URETERIC CALCULI Anuria

  • 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
ESWL COMPLICATIONS Anuria

  • 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 )



Renal lithiasis blood pressure study patients treated 1984 1986 dallus study
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 1984-1986 Dallus Study)

“SHOCK WAVE”

Lithotripsy


Fragmentation by shock waves
FRAGMENTATION BY SHOCK WAVES 1984-1986 Dallus Study)

ON COLLISION OF “ SHOCK WAVES” WITH CALCULI-

  • ON FRONT SURFACE – COMPRESIVE FORCES

  • ON BACK SURFACE OF THE STONE-

    REFLECTION 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
ESWL – SPARK GAP/ EHL 1984-1986 Dallus Study)

  • 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 Rapidly-

    evaporates Water & Generators A “Shock Wave” by expanding Sarrounding Liquid


Mechanism of stone fragmentation by eswl
Mechanism of Stone Fragmentation by ESWL 1984-1986 Dallus Study)

  • On Front Surface – Compresive or positive Forces

  • On Back Surface Of The Stone-

    Reflection 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
Steinstrasse ( or Stone Street) – 1984-1986 Dallus Study)Post ESWL


Diet fluid advice
Diet & Fluid Advice 1984-1986 Dallus Study)

  • 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
LIQUIDS 1984-1986 Dallus Study)

Moderate Amounts : High Amounts :

Apple Juice Cocoa

Beer Fresh Tea

Coffee

Cola

FOODS :

Almonds, Asparagus, Cashew Nuts, Currants, Greens, Plums, Raspberries, Spinach


Hippocratic oath
HIPPOCRATIC OATH : 1984-1986 Dallus Study)

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


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