STONE DISEASE

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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.
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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 20.2Phosph
  ate
• 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

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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
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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

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SOME DISEASES ASSOCIATED WITH HYPERCALCAEMIA
HYPERCALCIURIA

• Hyperparathyroidism Leukemia
• Sarcoidosis Lymphoma
• Multiple myeloma Myxedema
• Hyperthyroidism Adrenal Insufficiency
• Metastatic Malig. Neoplasm's Vit. D Intoxication

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TYPES OF KIDNEY / URETER STONES

• OXALATE (CALCIUM OXALATE)
• PHOSPHATE
• URIC ACID URATE
• CYSTINE

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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. 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)

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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

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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

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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

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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
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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
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PHOSPHATE STONES

• IN ALKALINE URINE ENLARGES RAPIDLY TAKE
  SHAPE OF CALYCES STAGHORN

Struvite can form Stag-horn and appear like
coffin lid under microscope
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CALCIUM PHOSPHATE STONES

• 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
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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
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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
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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
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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

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HISTORY

• A. IS PATIENT DRINKING ENOUGH ?
• B. PROFESSION
• C. ENQUIRE ABOUT UTI STONES
• D. FAMILY HISTORY
• E. LONG ILLNESS BEDRIDDEN STONES

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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
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HISTORY (Cont...)

• B. ASK ABOUT THEIR PROFESSION DEHYDRATION
  STONES CAN FORM e.g.
• MARATHON NEAR A FURNACE,
• BRICK - LAYER, LABOURERS WEAVERS
• TRUCK BUS DRIVERS

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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
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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
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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

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ON EXAMINATION

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

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INVESTIGATIONS

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

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INVESTIGATIONS (Cont...)

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

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INVESTIGATIONS (Cont...)

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

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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

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INVESTIGATIONS (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.

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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.
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MANAGEMENT OF UROLITHIASIS

• 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

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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
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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)

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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.

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ESWL For Urinary Tract Calculus
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ESWL- FOUR MAIN ELEMENTS

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

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ESWL

• Absolute Contra-indication-
• Pregnancy
• Relative Contra-Indications for ESWL
• Renal Colic
• Urinary obstruction
• Infection
• Declining Renal Function
• Significant Hematuria

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COUPLING DEVICE

• WATER BATH
• WATER FILLED CUSHION
• (KEEP PATIENTS DRY)

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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

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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

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COMPRESSION-TENSILE WAVE CAUSES

• Implosion Rather than Explosion

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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

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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 gt
  1.5 cm )

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DESIGN BASIC LITHOTRIPSY
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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

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• Basic Principles of
• SHOCK WAVE
• Lithotripsy

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FRAGMENTATION BY SHOCK WAVES

• 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

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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 Rapidly-
• evaporates Water Generators A Shock Wave by
  expanding Sarrounding Liquid

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Mechanism of Stone Fragmentation by ESWL

• 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

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Steinstrasse ( or Stone Street) Post ESWL
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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
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LIQUIDS

• Moderate Amounts High Amounts
• Apple Juice Cocoa
• Beer Fresh Tea
• Coffee
• Cola
• FOODS
• Almonds, Asparagus, Cashew Nuts, Currants,
  Greens, Plums, Raspberries, Spinach

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HIPPOCRATIC OATH

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