RENAL CALCULI

Etiology
It is complex, summary of current opinion:

1.Dietetic
Deficiency of vitamin A causes desquamation of epithelium
forming a nidus on which a stone is deposited. This mechanism is
probably active in the formation of bladder calculi.
2.Altered urinary solutes and colloids
Dehydration concentrates urinary solutes until they precipitate
Reduction of urinary colloids, which adsorb solutes, or
mucoproteins, which chelate calcium, might tend to crystal and
stone formation.
3.Decreased urinary citrate
The presence of citrate in urine, 300–900 mg per 24 hours, as
citric acid, keeps relatively insoluble calcium phosphate and
citrate in solution.
4.Renal infection
Infection favor’s the formation of urinary calculi. Clinical and
experimental stone formation are common when urine is infected
with urea-splitting streptococci, staphylococci and especially
Proteus spp.
5.Inadequate urinary drainage and urinary stasis
Stones are liable to form when urine is static.
6.Prolonged immobilization
Immobilization is liable to result in skeletal decalcification and an
increase in urinary calcium favoring the formation of calcium
phosphate calculi.

7.Hyperparathyroidism
Hyperparathyroidism leading to hypercalcemia and hypercalciuria
is found in 5% . A parathyroid adenoma should be removed
before definitive treatment for the urinary calculi.

Types of renal calculus

1.Oxalate calculus (calcium oxalate):

Oxalate stones are irregular with sharp projections. A calcium
oxalate monohydrate stone is hard and radiodense.
2. Phosphate calculus:
A phosphate calculus (calcium phosphate often with ammonium
magnesium phosphate (struvite) is smooth and dirty white. It
grows in alkaline urine, especially when urea-splitting Proteus
organisms are present. The calculus may enlarge to fill most of
the collecting system, forming a stag-horn calculus.
3. Uric acid and urate calculi:
These are hard, smooth and often multiple and multifaceted. Pure
uric acid stones are radiolucent. CT important to diagnose it.
Most uric acid stones contain some calcium, so they cast a faint
radiological shadow.
4. Cystine calculus
An uncommon congenital error of metabolism leads to cystinuria.
Cystine stones are often multiple and may grow to form a cast of
the collecting system. Cystine stones are radio-opaque and
very hard.

Clinical features
Renal calculi are common. Approximately 50 per cent of patients
present between the ages of 30 and 50 years. The male–female
ratio is 4:3. Renal failure may be the first indication of
bilateral silent calculi, although secondary infection usually
produces symptoms first.
Pain
Pain occurs in 75 per cent of people with urinary stones. Fixed
renal pain occurs in the renal angle, the hypochondrium, or in
both. Ureteric colic is an agonizing pain passing from the loin to
the groin. Pain resulting from renal stones rarely lasts more than
8 hours in the absence of infection. There is no pyrexia. Ureteric
colic is often caused by a stone entering the ureter but it may
also occur when a stone becomes lodged in the pelviureteric
junction. The severity of the colic is not related to the size of the
stone.
Ureteric colic
■ Severe exacerbations on a background of continuing pain
■ Radiates to the groin, penis, scrotum or labium as the stone
progresses down the ureter
■ Severity of pain is not related to stone size
■ Haematuria is very common
■ There may be few physical signs, tender bimanual exam.
Kidney.

Abdominal examination
During an attack of ureteric colic, tenderness present, Percussion
over the kidney produces a stab of pain and there may be
tenderness on gentle bimanual palpation. Hydronephrosis or
pyonephrosis leading to a palpable loin swelling is rare.

Haematuria
Haematuria, usually small in amount, is common and sometimes
is the only symptom of stone disease.

Pyuria (renal infection)

Infection of kidney is common complication of obstruction, and a
septicemia can quickly develop, Stones may cause pyuria by
irritating the urothelium even in the absence of infection.
Investigation of suspected urinary stone disease:

X-ray
The ‘KUB’ film shows the kidney, ureters and bladder. About 80-
85%, of renal stone are radiopaque, visualized in KUB.
Opacities on a plain abdominal radiograph that may be confused with renal calculus:

■ Calcified mesenteric lymph node

■ Gallstones or concretion in the appendix
■ Tablets or foreign bodies in the alimentary canal.
■ Phleboliths – calcification in the walls of veins, especially in the pelvis
■ Ossified tip of the 12th rib
■ Calcified tuberculous lesion in the kidney
■ Calcified adrenal gland

CT scan:
CT, preferably spiral, has become the mainstay of investigation of
acute ureteric colic. but non-contrast CT- scan is the main stay for
diagnosis of urolithiasis.

Excretion urography
IVU will establish the anatomy of urinary passages and presence
and position of a calculus and give a hint about function of the
other kidney.

Ultrasound scanning
Ultrasound scanning is of value in locating stones for treatment
by extracorporeal shock wave lithotripsy (ESWL).

treatment of urinary calculi:

A. Conservative management

Calculi smaller than 0.5 cm pass spontaneously unless they are

impacted. Surgical intervention should be avoided. Small renal
calculi may cause symptoms by obstructing a calyx or acting as a
focus for secondary infection that need urgent intervention. Most
can be safely observed until they pass.

B. Modern methods of stone removal Kidney stones:

Most stones should be treated by minimal access and minimally

invasive when the stone larger than 0.5 mm techniques.
preoperative treatment with Antibiotic treatment starts before
surgery and continues afterwards.

1.Extracorporeal shock wave lithotripsy:

stones disintegrate under the impact of shock waves produced
by the ESWL machine. The shocks may be aimed by ultrasound or
x-ray imaging. by using special frequency and power, can be
given without general anesthesia with minimal pain and may use
analgesia or sedative treatment.
Ureteric colic is common after ESWL, and the patient needs
analgesia, usually in the form of a non-steroidal anti-inflammatory
drug. Bulky stone fragments may impact in the ureter, causing
obstruction. To avoid this, a JJ stent should be placed in the ureter
to drain the kidney while stone fragments pass. Occasionally,
impacted fragments have to be removed ureteroscopically.
The principal complication of ESWL is infection. So, prophylactic
antibiotics before ESWL.
If obstructed system should be decompressed by a ureteric stent
or percutaneous nephrostomy before treatment.
The clearance of stone from the kidney will depend upon the
consistency of the stone and its site.
The clearance of stone fregments, after ESWL depending on the
type of stone , site, and size.

2.Percutaneous nephrolithotomy (PNL):

Endoscopic instruments are passed into the kidney by a
percutaneous technique. Small stones may be grasped under
vision and extracted whole. Larger stones are fragmented by an
ultrasound, laser or electrohydraulic probe and removed in
pieces. The aim is to remove all fragments. A nephrostomy drain
is left in the system when the procedure is complete. This
decompresses the kidney and allows repeated access if
necessary.
Percutaneous nephrolithotomy is sometimes combined with ESWL
in the treatment of complex (stag-horn) calculi.
Complications of percutaneous nephrolithotomy include:
(1) haemorrhage from the punctured renal parenchyma;
(2) perforation of the collecting system with extravasation of
saline irrigant; (3) perforation of the colon or pleural cavity during
placement of the percutaneous track.

3. retrograde intrarenal surgery (RIRS):

Special new technique using flexible uretro-renoscopy, passing
through urethra reaching the renal pelvis guided sometime by
fluoroscopy, using laser fiber for destruction renal stones.
It is indicated when small stone less tha15 mm diameter, or small
stones not responding to ESWL or small stone in lower calyx.

Open surgery for renal calculi

Operations for kidney stone are usually performed via a loin or
lumbar approach.
It is indicated, when it large stone as staghorn stone, or failure of
previous procedures m or if associated with special congenital
anatomy of the kidney or body deformity as kyphosis, or scoliosis.

Pyelolithotomy
indicated if the stones in the renal pelvis, by extraction of the
stone from it.

Extended pyelolithotomy: by doing wide incision to renal pelvis for stone

extraction.
 or Nephrolithotomy:
(incisions into the renal parenchyma) to clear the kidney.
Sometime Partial nephrectomy is sometimes preferable for a
stone in the lowermost calyx with infective damage to the
adjacent parenchyma.
A functionless kidney destroyed by stone disease may do
nephrectomy.

Treatment of bilateral renal stones

Usually the kidney with better function is treated first, unless the
other kidney is more painful or there is pyonephrosis which needs
urgent decompression.

Prevention of recurrence
Ideally, stone formers should be investigated to exclude
metabolic factors, with, and the urine should be screened for
infection.
The following investigations are appropriate in bilateral and
recurrent stone formers:
• serum: for calcium, parathyroid hormone for
hyperparathyroidism;
• serum uric acid;
•24-hour collection :for urinary urate, calcium and phosphate ,
cystine , oxalate ,also for citrate and magnesium.
• analysis of stone.

*Dietary advice is not usually helpful in avoiding stone

recurrence in people who have a balanced diet.

*Patients with hyperuricemia should avoid red meats, offal and

fish, which are rich in purines, and should be treated with
allopurinol.

*should drink plenty water to keep their urine dilute.

*Drug treatment is largely ineffective except in those few patients
who are shown to have idiopathic hypercalciuria.
* a calcium-restricted diet reduces urinary calcium.

*■ Stones are more common in those who have

had a previous stone. Unless there is a
specific biochemical abnormality,
high fluid intake is the best prophylactic
measure

URETERIC CALCULUS

A stone in the ureter usually comes from the kidney. Most

pass spontaneously.

Clinical features
A stone passing down the ureter often causes intermittent attacks
of ureteric colic.
Ureteric colic
The waves of agonizing loin pain are typically referred to the
groin, external genitalia and the anterior surface of the thigh. As
the stone enters the bladder, the pain can be referred to the tip of
the penis.

stone Impaction:
There are five sites of narrowing where the stone may be
arrested.

1. Ureteropelvic junction
2. Crossing the iliac artery
3. Juxtaposition of vas deferens or broad ligament
4. Entering the bladder wall
5. Ureteric orifice.

An impacted stone causes a more consistent dull pain, often in

the iliac fossa . Distension of the renal pelvis due to obstruction
may cause loin pain. The stone may become embedded as the
adjacent ureteric wall becomes eroded and edematous as a result
of pressure ischemia. Perforation of the ureter and extravasation
of urine is a rare complication.
Severe renal pain subsiding after a day or so suggests complete
ureteric obstruction.

If obstruction persists after 1–2 weeks, the calculus should be

removed to avoid pressure atrophy of the renal parenchyma.

Haematuria
Almost all ureteric colic is associated with transient microscopic
haematuria. Serious bleeding is uncommon and should suggest
clot colic.

Abdominal examination
There is tenderness on the course of the ureter.

The presence of haematuria does not rule out

appendicitis because an inflamed appendix can give rise
to a local ureteritis leaking some red cells into the urine.

The patient with acute ureteric colic is usually in greater

pain and less ill
than one with appendicitis or acute cholecystitis.

Imaging for diagnosis:

KUB: Most urinary calculi are radio-opaque. Stones are difficult to

see if small or obscured by bowel contents or nearby bones.
 IVU while the patient has pain can confirm the diagnosis, there
will probably be little or no, excretion on the affected side In
ureteric colic.

spiral CT is preferable.

Cystoscopy is not indicated for diagnosis. Sometime ureteroscopy

my indicated as diagnostic and therapeutic.

Treatment
Pain
Non-steroidal anti-inflammatory drugs, such as diclofenac and
indomethacin, have replaced opiates as the first line of treatment
for renal colic. The value of smooth muscle relaxants, such as
propantheline (Pro-Banthine), is debatable.
Removal of the stone
Expectant treatment is appropriate for small stones likely to pass
naturally. If the patient is not disabled by recurrent attacks of
colic, progress can be followed by x-rays every 6–8 weeks.

Indications for surgical removal of a ureteric

calculus
* Repeated attacks of pain and the stone is not moving
*Stone is enlarging
*Complete obstruction of the kidney
*Urine is infected
*Stone is too large to pass
*Stone is obstructing solitary kidney or there is bilateral
obstruction

*or arrested stone in ureter with partial obstruction 6 weeks.

Endoscopic stone removal
1.Dormia basket
by use wire baskets under image intensifier control has been.
There is a danger of ureteric injury even with small stones. now
use it with ureteroscopy guide.

2.Ureteric meatotomy
Endoscopic incision with a diathermy knife will enlarge the
opening and free a stone lodged in the intramural ureter.

3.Ureteroscopic stone removal

A ureteroscope is introduced transurethrally across the bladder
into the ureter to remove stones impacted in the ureter, under
direct vision are fragmented using an electrohydraulic ,pneumatic
or laser lithotripter.

4.Push bang
A stone in the middle or upper part of the ureter can often be
flushed back into the kidney using a ureteric catheter. A J-stent
secures the calculus in the kidney for subsequent treatment with
ESWL.

A flexible fiberoptic ureteroscope can be used for laser

destruction of calculi in the renal collecting system or ureter and
to retrieve small stones from the kidney.

5.Lithotripsy in situ
A stone in a part of the ureter that can be identified by the
imaging system of the lithotripter can be fragmented in situ.
Using ESWL, This form of treatment is not appropriate if there is
complete obstruction or if the stone has been impacted for a long
time.
6.Open surgery
Ureterolithotomy
rarely used now days unless failure of previous option of
treatment or if associated with anatomical abnormality.

Dr. Mohammed R. Judi Jalo

Professor of urology

2024-2025