1. URINARYSTONE DISEASE DEPARTMENT OF UROLOGY IAŞI – 2013

2. INTRODUCTION • 3rd most common condition of the urinary tract (1 – UTIs, 2 – prostate diseases) • stone recurrence rates – 50% within 5 years !

3. RENAL & URETERAL ETIOLOGY • composition = crystals + organic matrix (2-10%) • supersaturated urine  stone formation • urinary pH • ionic strength (concentration of monovalent ions) • solute concentration (concentration of 2 ions, solubility product, formation product) • complexation (Na – oxalate, sulfate – Ca) • inhibitors (magnesium, citrate, pyrophosphate, trace metals) • nucleation theory – crystals or foreign bodies immersed in supersaturated urine • crystal inhibitor theory – absence or low concentration of natural stone inhibitors

4. RENAL & URETERAL • nucleation (heterogeneous – epitaxy !), growth & aggregation  stone formation • retention in the upper urinary tract (nephrocalcinosis !) • mass precipitation theory (intranephronic calculosis) • fixed particle theory – Randall plaques, Carr corpuscles • matrix calculi – previous kidney surgery & chronic UTIs STONE VARIETIES Calcium Calculi (80-85%) • absorptive hypercalciuria –  Ca absorption  Ca filtered (glomerulus)   PTH   tubular reabsorption of Ca  Ca ur • resorptive hypercalciuria – primary hyperparathyroidism (parathyroid adenoma)  P ur,  P sr Ca sr,  Ca ur  renal damage  Ca ur

5. RENAL & URETERAL • renal hypercalciuria – intrinsic renal tubular defect in calcium excretion  Ca ur   Ca sr  PTH (secondary)  Ca resorbtion (bone) & absorption (gut)  Ca ur • hyperuricosuria • hyperoxaluria – primary or enteric (inflammatory bowel disease) • hypocitraturia – metabolic acidosis, hypokalemia (thiazide therapy), fasting, hypomagnesemia, androgens, UTI Noncalcium Calculi • struvite – magnesium, ammonium and phosphate • uric acid • cystine – autosomal recessive • xanthine, indinavir, silicate, triamterene

6. RENAL & URETERAL SYMPTOMS & SIGNS AT PRESENTATION Pain • renal colic • noncolicky renal pain Hematuria Infection – pyonephrosis, xanthogranulomatous pyelonephritis Fever, Anuria !, Nausea and Vomiting EVALUATION Risk Factors – crystalluria, socioeconomic factors, diet, occupation, climate, family history, medications Physical Examination Imaging Investigations – US, KUB film, IVU, CT (noncontrast spiral), retrograde pyelography, nuclear scintigraphy

7. RENAL & URETERAL Differential Diagnosis – acute appendicitis, ectopic pregnancies, twisted ovarian cysts, diverticular disease, bowel obstruction, biliary stones, peptic ulcer disease, acute renal artery embolism, abdominal aortic aneurysm etc. INTERVENTION Conservative Observation – spontaneous passage! Dissolution Agents – oral alkalinizing agents (sodium or potassium bicarbonate and potassium citrate), i.v. alkalinization (sodium lactate), intrarenal alkalinization (sodium bicarbonate) – acidification – hemiacidrin (Renacidin) Relief of Obstruction – JJ ureteral stent, PNS

8. RENAL & URETERAL ESWL (Extracorporeal Shock Wave Lithotripsy) • electrohydraulic, piezoceramic, electromagnetic • approximately 75% of patients with renal calculi (< 1.5-2 cm) treated with ESWL become stone-free in 3 months

9. RENAL & URETERAL Ureteroscopic Stone Extraction • highly efficacious for lower ureteralcalculi • stone-free rates range from 66-100% • lithotrites – electrohydraulic, ultrasonic,laser, pneumatic

10. RENAL & URETERAL Percutaneous Nephrolithotomy • choice for large (> 2 cm) calculi, thoseresistant to ESWL, select lower polecalyceal stones and instances withevidence of obstruction • Remaining calculi can be retrievedwith flexible endoscopes, additionalpercutaneous puncture access,follow-up irrigations, ESWL, oradditional percutaneous sessions

11. RENAL & URETERAL Open Stone Surgery • pyelolithotomy • anatrophic nephrolithotomy • radial nephrotomy • nephrectomy • ureterolithotomy

12. BLADDER • manifestation of an underlying pathologiccondition, including voiding dysfunction(urethral stricture, BPH, bladder neckcontracture, neurogenic bladder) or aforeign body • irritative voiding symptoms, intermittenturinary stream, urinary tract infections,hematuria, or pelvic pain • US • electrohydraulic, ultrasonic, laser,pneumatic and mechanical lithotrites • cystolithotomy