RENAL CALCULI

&
URETERIC CALCULI

DR SURAJIT LAHIRI
MBBS (Cal); MS (Cal); DNB (Gen Surg)
PROFESSOR
Department of Surgery
ESI-PGIMSR & ESIC Medical College, Joka
Kolkata
 AETIOLOGY OF RENAL CALCULI
• Dietetic
– Diet rich in red meat, fish & eggs cause aciduria
– Diet rich in calcium (tomatoes, milk, spinach) produce calcium oxalate stones
– Diet lacking vitamin A cause desquamation of epithelium forming nidus for
calcium deposition resulting in stone formation (Epitaxy)

• Altered urinary solutes & colloids

– Dehydration concentrates urinary solutes until they precipitate
– Reduction of urinary colloids (absorb solutes) or mucoproteins (chelate calcium)
helps stone formation

• Decreased urinary citrate

– Citrate in urine (300-900 mg/24hrs) as citric acid keeps relatively insoluble
calcium phosphate and citrate in solution by reducing pH

• Urinary stasis & inadequate urinary drainage

– Induces stone formation
 AETIOLOGY OF RENAL CALCULI (Contd.)
• Renal infection
– Stone formation is common when urine is infected with urea-splitting
streptococci, staphylococci & especially Proteus sp.

• Prolonged immobilization
– Immobilization causes skeletal decalcification which increases urinary
calcium favouring formation of calcium phosphate calculi

• Metabolic cause
– Hyperparathyroidism cause hypercalcaemia & hypercalciuria favouring
multiple stone formation
– Gout increases uric acid levels favouring uric acid stones

• Randall’s plaques
– Randall suggested that initially a small erosion or an ulcer develops at the tip
of renal papilla on which minute concretions or minor calcium particles get
deposited which eventually results in stone formation
 TYPES OF RENAL STONES
• Calcium oxalate stone
– Common type of stone also called mulberry
calculi
– Irregular with sharp projections
– Induces bleeding hence black in colour due to
blood over the stone
– Hard and single
– Radiodense
– Occurs in infected urine

• Uric acid stone

– Yellow coloured hard, smooth and often
multiple, multifaceted
– Pure uric acid stone is radiolucent
– Occurs in acidic urine
– Common in patients who consume a lot of red
meat
– Best responsive to lithotripsy
 TYPES OF RENAL STONES (contd.)
• Phosphate stone
– Usually a triple phosphate stone - struvite (calcium,
magnesium & ammonium phosphate stone)
– Grows in alkaline urine, especially when urea-
splitting Proteus organisms are present
– Stag-horn calculus usually occupying the renal pelvis
– Usually asymptomatic until the stone is big
– Presents with haematuria, urinary infection or renal
failure
– Dirty white to yellow in colour
– Radiodense

• Cystine stone
– Cystinuria is an inborn error of metabolism due to
decreased reabsorption of cystine from the renal
tubules
– Usually occurs in young girls at puberty
– Stones are very hard & radiodense due to sulphur
 CLINICAL FEATURES OF RENAL CALCULI
• Age
– 50% of patients present between the ages 30 & 50 years
• Sex ratio
– Male-female ratio is 4:3
• Silent calculus
– Renal failure may be the first indication of silent stone
– Secondary infection is commoner
• Renal pain
– Fixed dull aching to pricking pain over renal angle or hypochondrium or
both
– Worsens on movement
– Nausea & vomiting
• Recurrent UTI
– Fever with chill & rigor
– Burning micturition
– Increased frequency
 CLINICAL FEATURES OF RENAL CALCULI (contd.)
• Ureteric colic
– severe colicky pain radiating from loin to
groin, testicles/vulva and medial aspect of
thigh when the stone is impacted in the
pelviureteric junction or anywhere in the
ureter
– It may be associated with strangury
– Referred pain is due to irritation of
genitofemoral nerve
• Haematuria
– Common as most of the stones are oxalate
stones
– Minimal blood loss
• Pyuria
– Infection is particularly dangerous when the
kidney is obstructed
• Guarding and rigidity
– Back and abdominal muscles are affected
 COMPLICATIONS OF RENAL STONES
• Calculus hydronephrosis
– Obstruction to flow of urine cause back pressure which cause enlargement of
kidney
– Stretching of kidney parenchyma causes pain
– Hydronephrotic kidney can be palpated as renal mass on bimanual examination

• Calculus pyonephrosis
– Infected hydronephrosis
– Kidney changes to a bag of pus

• Renal failure
– Bilateral stag-horn calculus may not be symptomatic and can present with
uremia and renal failure

• Squamous cell carcinoma

– Long standing stones increases risk of carcinoma
 INVESTIGATIONS
• Blood urea & creatinine
– To rule out renal failure

• Urine for culture & sensitivity

– To pinpoint organisms & to select sensitive antibiotics

• USG of KUB region

– Presence of stone can be confirmed
– Exact size and location of stone can be evaluated
 INVESTIGATIONS (contd.)
• Plain X-ray KUB
– 90% of renal stones are opaque
– Enlarged renal shadow can be
seen in hydronephrosis

D/D of renal stones on

plain X-ray KUB
• Calcified mesenteric LN
• Gallstones or concretions in
the appendix
• Tablets or FB within gut
• Phleboliths
• Ossified tip of 12th rib
• Calcified TB lesion in the
kidney
• Calcified adrenal gland
 INVESTIGATIONS (contd.)

• IVP
– Shows exact location of the stone
– Bilateral renal function can be assessed
– Hydronephrosis & hydronephroureterosis can be seen
– Radiolucent stone can be seen as filling defect

5 min 30 min 60 min Right-sided hydronephrosis

with ureteric calculi
 INVESTIGATIONS (contd.)

• Contrast-enhanced CT scan
– CT scan, especially spiral CT, has become the mainstay
investigation for acute ureteric colic
 NON-OPERATIVE TREATMENT

• Conservative
– Stones smaller that 5mm pass spontaneously unless
impacted
– Stones between 5-7mm are doubtful
– Copious fluids
– Forced diuresis may be required
 NON-OPERATIVE TREAMENT (contd.)
• Extracorporeal shock wave lithotripsy (ESWL)
– Crystalline stones disintegrate under the impact of shock waves produced by the ESWL machine
– Holmium-YAG laser (Ho-YAG) is the most effective with good margin of safety
– Shocks are aimed by USG or X-ray imaging
– Ureteric colic is common after ESWL
– NSAID’s are effective in controlling pain
– Ureteric DJ stent is given to prevent ureteric obstruction by passing stones
– Commonest complication of ESWL is infection
– Obstructed system should be decompressed by a ureteric stent or percutaneous nephrostomy
– Oxalate & phosphate stones fragment well but results for cystine stones are less satisfactory
– It takes months to clear calyceal stones
 CLOSED OPERATIVE TREATMENT
• Percutaneous nephrolithotomy (PCNL)
– Endoscopic instruments are passed into the kidney by a percutaneous
technique
– Small stones are grasped under vision and removed whole
– Large stones are fragmented by an ultrasound, laser or
electrohydraulic probe and removed in pieces
– Nephrostomy drain is given
– Complications include
• Haemorrhage
• Perforation of the collecting system
• Perforation of the colon or pleural cavity
 OPEN OPERATIVE TREATMENT
• Pyelolithotomy
– Indicated for stones in extrarenal pelvis
– Incision is in its long axis directly on the
stone
– If there is sepsis nephrostomy is
essential to drain the system
• Extended pyelolithotomy
– Kidney parenchyma is retracted
laterally & incision over pelvis is
extended over to the calyx
– Large stag-horn calculus can be
removed intact
• Pyelonephrolithotomy
– Stone is extracted through an incision Pyelolithotomy
in the pelvis as well as the renal
parenchyma
 OPEN OPERATIVE TREATMENT(contd.)
• Nephrolithotomy
– In case of intra-renal pelvis stone is extracted through the renal
parenchyma
– Also done when adhesions from previous operation complicates
access to the renal pelvis
– Renal pedicle is temporarily cross-clamped
– Incision made posterior and parallel to the most prominent part of the
convex renal border (Brodel’s line)
– Cooling extends the ischaemic time
– Incision is closed with haemostatic sutures
– Guard against reactionary haemorrhage
• Partial nephrectomy
– Done for stone impacted in the lower-most calyx with infective
damage to the adjacent parenchyma
• Nephrectomy
– Functionless kidney destroyed by stone disease should be removed
 TREATMENT(contd.)
• Bilateral stones
– Kidney with better function is operated first, unless the other kidney is
more painful or there is pyonephrosis needing urgent decompression
– Other kidney is operated after 1-2 weeks

• Prevention of recurrence
– Investigations done include
• Urine is screened for infection
• Serum calcium is measured to rule out hyperparathyroidism
• Serum uric acid
• Urinary urate, calcium and phosphate in 24 hrs
• Urine is screened for cystine
• Stone analysis
– Dietary advice
– Plenty of water
– Drugs (e.g. Bendroflumethiazide, Zyloric)
URETERIC CALCULI
 CLINICAL FEATURES
• Origin
– Stones in the ureter usually come from the kidney and most of them pass
out spontaneously
• Ureteric colic
– Loin to groin pain typically referred to the external genitalia and anterior
surface of the thigh
– When stone enters the urinary bladder pain is referred to the tip of penis
• Haematuria
– Almost all renal colic is associated with transient microscopic haematuria
– Serious bleeding is rare and suggests clot colic
• Abdominal examination
– Tenderness and rigidity over the course of the ureter
– Patient with ureteric colic is in greater pain but looks less ill compared
to a patient of acute appendicitis or acute cholecystitis
 CLINICAL FEATURES(contd.)
• Impaction
– There are five sites of natural narrowing
along the course of the ureter where
the stone can get impacted
– Impacted stone gives dull aching fixed
pain
– Distention of renal pelvis due to
obstruction cause hydronephrosis and
loin pain
– Stone may perforate the ureter with
extravasation of urine
– If obstruction is not relieved after 1-2
weeks, the calculus should be removed
to avoid pressure atrophy of renal
parenchyma
 IMAGING
• Most urinary stones are radio-opaque

• IVU during renal colic confirms the diagnosis

• Spiral CT is the best investigation for ureteric

colic

• There is little or no excretion on the affected

side

• Delayed x-rays shows dilatation of ureter up to

the stone

• Cystoscopy if done shows edema around the

ureteric orifice when the stone is nearby

• Retrograde ureterography is performed

immediately prior to an endoscopic operation to
remove a calculus
 TREATMENT

• Pain
– NSAID (diclofenac & indomethacin)

• Removal of stone
– Expectant treatment is appropriate for small stones (< 5mm)
– Indications for surgical removal of ureteric calculi
• Stone not moving despite repeated attacks of pain
• Stone is increasing in size
• Complete obstruction of the kidney
• Urine is infected
• Stone is too large to pass (> 7mm)
• Stone is obstructing solitary kidney or there is bilateral obstruction
 ENDOSCOPIC TREATMENT
• Dormia basket
– Wire baskets introduced under image intensifier to
remove ureteric stone.
– Injury to ureter is a possibility with small stones
• Ureteric meatotomy
– Endoscopic incision of ureteric meatus in the urinary
bladder with a diathermy knife enlarges the opening
and helps removal of stone
– Urinary reflux rarely causes problem
• Ureteroscopic stone removal
– Ureteroscope is introduced transurethrally across the
bladder into the ureter to remove stones from ureter
– Bigger stones are fragmented using an electro-
hydraulic, percussive or laser lithotripter
• Push bang
– Stone in middle or upper ureter is pushed back into
the kidney using ureteric catheter
– Stone is secured by J-stent and ESWL performed
• Lithotripsy in situ
– Stone is fragmented in situ by the lithotripter
– Complete urinary obstruction and impaction of stone
for a long time are contraindications of this procedure
 OPEN TREATMENT
• Ureterolithotomy
– Position of the stone is confirmed immediately prior to surgery
– Calculi in upper 1/3 ureter is approached through a loin or upper
quadrant transverse incision
– Calculi in middle 1/3 ureter is approached through a muscle-cutting iliac
fossa incision
– Calculi in lower 1/3 ureter is approached through a Pfannenstiel incision
– Slings are passed above and below to prevent stone from moving
– Ureter incised longitudinally directly on the stone
– Soft catheter is passed above and below to confirm there is no other
stone in ureter
– Ureterotomy is closed with interrupted absorbable sutures
– Drain is kept to drain urine leakage
THANK YOU