MANAGEMENT OF
UROLITHIASIS
DR LOVE WATTA
EVALUATION
Urinary stones should be differentiated from other causes of acute abdomen
like acute appendicitis, ectopic and unrecognized pregnancies, ovarian
pathologies, bowel diseases, gall stones , vascular diseases etc.
RADIOLOGIC INVESTIGATIONS
COMPUTED
TOMOGRAPHY
Imaging modality of
choice.
Rapid, less expansive
than IVP .
Hounsfield units can
help predict stone
type and hardness.
Pose a risk for
radiation exposure.
Should not be used as
surveillance tool
IVP
Simultaneously document stone and upper tract anatomy
Xray KUB
USG
RETROGRADE PLEYOGRAPHY
CONSERVATIVE OBSERVATION
Passage of calculi depends upon size, shape, location and associated ureteral
oedema.
Ureteric stone of size < 5 mmhg has 50 % rate of spontaneous passage.
Stones in distal ureter has 50% , mid ureter 25% and proximal ureter 10 %
chance of spontaneous passage.
Medical Expulsive Therapy helps facilitate spontaneous passage of ureteric
stones, drugs like α blocker, NSAIDS with or without low dose steroids
optimise stone passage.
DISSOLUTION AGENTS
Effectiveness depends upon stone area, stone type, volume of irrigant and
mode of delivery.
Oral alkanizing agents used for uric acid stone include sodium or potassium
bicarbonate and potassium citrate. Causiouly used in pts with CCF or renal
failure. Citrus juices are good alternatives.
Intra renal alkalization can be done through nephrostomy drains. Agents used
are sodium bicarbonate and Tromethamine.
STRUVITE stones require acidification. Hemiacidrin is used.
RELIEF FROM
OBSTRUCTION
Double J stents.
Percutaneous
nephrostomy tubes.
EXTRACORPOREAL SHOCKWAVE
LITHOTRIPSY
Noted in Russia in 1950s, clinical application was successfully tried in 1980s
by DORNEIR, german aircraft company.
Sources of energy include:
SUPERSONIC EMITTERS
FINITE AMPLITUDE EMITTERS
PIEZOCERAMIC
ELECTROMAGNETIC
Requires fluoroscopic or USG guided localisation of stone.
Overweight, gross skeletal deformities may hinder SWL.
Pregnancy , vascular aneurysms, bleeding disorders, HTN are some
contraindications for SWL.
Disadvantage is specificity for certain stone size and hardness.
ENDOSCOPIC SURGERIES
Scopes based on their site of action are named accordingly and vary in size.
Energy sources
PNEUMATIC LITHOCLAST
LASER SYSTEMS
ULTRASONIC PROBES
ELECTROHYDRAULLIC
ELECTROMECHANICAL IMPACTERS
OPEN STONE SURGERY
Rarely used today.
Renal stones
PYELOLITHOTOMY
PYELONEPHROLITHOMY
NEPHROLITHOTOMY
Ureteric stone- URETEROLITHOTOMY
Bladder stone – CYSTOLITHOTOMY
PREVENTION
Adequate fluid intake resulting in around 1.5-2 litres of urine output/24 hrs.
Metabolic evaluation in recurrent case, urine analysis for calcium, uric acid,
oxalate, citrate, phosphate, sulfate, pH should be done.
Medications like oral alakanizing agents,
GI absorption inhibitors like CELLULOSE PHOSPHATE, calcium supplementation
in cases enteric hyperoxaluric cases.
Diuretics like THIAZIDES.
UREASE inhibitors like ACETOHYDROXAMIC ACID.
