SURGICAL PRESENTATION AND MANAGEMENT OF UROLITHIASIS

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1 SURGICAL PRESENTATION AND MANAGEMENT OF UROLITHIASIS INTRODUCTION Urinary Tract stones Are common May be clinically silent. Are usually visible on a plain abdominal radiograph May be radiolucent when composed of uric acid Approximately 50% of patients present between the ages of 30 and 50 years. The male female ratio is 4:3. INTRODUCTION Kidney stone is more common in renal pelvis. Ureteric stone is always of renal origin. Commonly is of elongated shape. Can get impacted at various narrow jucntion PUJ Crossing the iliac artery Crossing vas deferens. Intramuscular part of ureter and Ureteric meatus INTRODUCTION A primary bladder stone is one that develops in sterile urine; it often originates in the kidney. A secondary stone occurs in the presence of infection, outflow obstruction, impaired bladder emptying or a foreign body. ETIOLOGY Dietetic Deficiency of vitamin A causes desquamation of epithelium. Altered urinary solutes and colloids Dehydration increases the concentration of urinary solutes until they are liable to precipitate. Reduction of urinary colloids, which adsorb solutes, or

2 mucoproteins, which chelate calcium. Etiology Decreased urinary citrate Citrate in urine, as citric acid, tends to keep insoluble calcium phosphate and citrate in solution. Renal infection Infection favors the formation of urinary calculi. The bacteria found in urinary stones are staphylococci and Escherichia coli. Etiology Inadequate urinary drainage and urinary stasis Prolonged immobilization e.g. paraplegia, results in skeletal decalcification and an increase in urinary calcium. Hyperparathyroidism Hyperparathyroidism leading to hypercalcaemia and hypercalciuria is found in 5% or less of those who present with radioopaque calculi. Types of Stones in Urinary Tract Oxalate calculus (calcium oxalate). Irregular in shape and covered with sharp projections, which tend to cause bleeding. Phosphate calculus (Stag horn) It is a calcium phosphate often with ammonium magnesium phosphate (struvite), smooth, dirty white and Radio-opaque. It tends to grow in alkaline urine, especially when urea-splitting Proteus organisms are present. usually easy to see on radiographic films.

3 Oxalate calculi Types of Stones in Urinary Tract Uric acid and urate calculi Often multiple, they vary from yellow to reddish brown and multifaceted appearance. Pure uric acid stones are radiolucent and appear on an excretion urogram as a filling defect The uric acid stones is diagnosed by CT. Staghorn calculus.

4 Bladder Stone Types of Stones in Urinary Tract Cystine calculus Uncommon stones appear in the urinary tract of patients with a congenital cystinuria. Hexagonal, translucent, white crystals of cystine appear only in acid urine. Pink or yellow when first removed, they change to a greenish colour when exposed to air. Cystine stones are radioopaque because they contain sulphur. Types of Stones in Urinary Tract Xanthine calculus These are extremely rare. They are smooth and round, brick-red in color, and show lamellation on cross-section. Presentation Pain from the upper urinary tract When caused by acute obstruction of the renal pelvis, is typically fixed deep in the loin and bursting in character When caused by acute ureteric obstruction (usually by a stone), is colicky with sharp exacerbations against a constant background.

5 Is liable to be referred to the groin, scrotum or labium as calculus obstruction moves distally in the ureter. Presentation Pain from the lower urinary tract Is commonly felt as subrapubic discomfort, worsening as the bladder fills When caused by cystitis, typically has a burning or scalding character felt in the urethra on micturition May be referred to the tip of the penis in men, even when Stone is in the bladder PRESENTATION Symptoms are variable and the diagnosis sometimes remains obscure until the stone is discovered on a radiograph. Renal Stone Silent calculus Pain (75%) In Lumbar region, renal angle or flank Hematuria Micro and macroscopic Ureteric Stone Ureteric colic Severe exacerbation on a background of continuing pain Radiates to the groin, penis, scrotum or labium as the stone progresses down the ureter. Haematuria Pyuria. PRESENTATION Bladder stone Dysuria due to urinary infection is a common presenting symptom. Increased frequency of micturition. Strangury at the end of micturation, is referred to the tip of the penis or to the labia majora. In young boys, screaming and pulling the penis with the hand at the

6 end of micturition. passage of a few drops of bright-red blood at the end of micturition. Acute retention of urine small stone impacted. Investigation of suspected urinary stone disease Urine DR pus cell, red cells and nitrates Urine C/S organism causing infection Urea Creatinine 24 hours urinary nitrates mg/dl Electrolytes Serum calcium Serum Parathyroid Phosphate level Investigation of suspected urinary stone disease X-ray KUB film shows the kidney, ureters and bladder 90% radioopaque, 10% radiolucent ( uric acid stone) Excretion urography Intravenous Urography (IVU) Ultrasound scanning. Contrast-enhanced CT. Ureteroscopy. Cystoscopy. X-Ray KUB Showing Rt Renal Stone

7 Bladder Stone Treatment of urinary calculi Conservative management Calculi smaller than 0.5 cm pass spontaneously unless they are impacted. Infection in the presence of stone is an indication for urgent surgical intervention

8 Treatment of urinary calculi Surgical treatment of urinary calculi Preoperative treatment In case of urinary infection appropriate antibiotic treatment is started and continued during and after surgery as necessary. Operation for stone Most stones are treated by minimal access and minimally invasive techniques (PCNL). Open surgery is still needed when appropriate expertise is not available or newer techniques have failed to clear the calculus Treatment of urinary calculi Modern methods of stone removal Kidney stones Extracorporeal shock wave lithotripsy (ESWL) 2-3 cm stone size Percutaneous nephrolithotomy. When > 3cm and multiple stone. Failure of ESWL Open surgery for renal calculi Failure of PCNL and ESWL Pyelolithotomy. Extended pyelolithotomy. Nephrolithotomy. Treatment of urinary calculi Removal of Ureteric stones Endoscopic stone removal Push and bang stone in upper 3 rd of ureter pushed in renal pelvis followed by ESWL Dormia basket middle and lower 3 rd of ureter Ureteroscopic stone removal stone in middle and lower 3 rd of ureter Ureteric meatotomy stone impacted at the junction of

9 urterovesical junction. Lithotripsy in situ not appropriate if there is complete obstruction. Open surgery Ureterolithotomy Ureteroscopy. Radiograph showing a ureteroscope and guidewire in the lower ureter. Treatment of urinary calculi Removal of Bladder Stone Minimal invasive Litholopaxy Contraindication age less than 10 years Lithotrite. Open Technique Cystolithotomy. THE END!!!!!

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