By: Smriti Singh950111095

Urinary Stones are typically

classified by their location as:

NEPHROLITHIASIS (in kidney)

URETEROLITHIASIS ( in ureter)

CYSTOLITHIASIS ( in bladder)

NEPHROLITHIASIS :

A condition marked by the presence of Renal Calculus/ Nephrolith.

Incidence : approxly 2% of population

Peak onset : 20 - 35 years of age

More common in males ( ratio – 2:1)

Etiology/Risk Factors : Infection: By proteus, E.coli,Recurrent UTI,

Diet: Vit A deficiency, Calcium rich diet etc.

Hot Climate . Metabolic causes: Gout, hyperoxaluria etc

Immobilisation.

Others: decreased urinary citrate, stasis, dehydration,sedentary lifestyle etc.

Pathophysiology/ Stone Formation:

Urine Supersaturation

Nucleus Formation

Crystallisation& Aggregation

Matrix Formation

STONE

Types Of Stones:• Hard, single, brown in

colour

• Mulberry stones

Calcium Oxalate stones (75%)

• Smooth, round ,white in colour

• Staghorn calculus

Phosphate stones (10-15%)

• Multiple, yellowish,radioluscent

• Seen in gout etc

Uric acid stones(5%)

• Seen in cystinuria,

• Hard, radio-opaque due to sulphur

Cystinestones (2%)

Clinical Features:

Renal pain

Guarding and Rigidity

Ureteric Colic

Hematuria

Pyuria, Fever

Recurrent UTI

Investigations: Blood and Urine Test

Plain X-ray, KUB

USG

IVP

RGP

CT scan (contrast/ non contrast)

Urine for culture and sensitivity.

Treatment:

• Conservative: Flush Therapy;I.V fluids; Inj frusemide

• ESWL (Extracorporeal Shock Wave Lithotripsy)

Non-Operative

• Endoscopic procedures: PCNL (percutaneousnephrolithotomy)

• Surgical proceduresOperative

ESWL(Extracorporeal Shock Wave Lithotrispy)

Electromagnetic Shock waves are produced.

Dornier Lithotripter is used for fragmenting stones.

Advantages: No anaesthesiaNo incisionNo Pain

Complications: Renal haematomaSevere haematuriaSteinstrasse (stone street)

• Contraindications: PregnancyBleeding disordersAbdominal aneurysm

PCNL (Percutaneous Nephrolithotomy)

Indications:

- Stones not responding to ESWL

- Stones more than 2.5 cm in size- Multiple Stones

Complications:- Haemorrhage- Injury to colon or pluera- Perforation of collecting duct

Steps:

SURGERIES Pyelolithotomy: for

stones in extrarenal pelvis.

Extended Pyelolithotomy.

Nephrolithotomy. Pyelonephrolithotomy. Partial Nephrectomy. Nephrectomy. Coagulum

pyelolithotomy

URETERIC CALCULI:

Always of renal origin.

Stones gets impacted at sites of ureteric narrowing, namely

1. PelviuretericJunction(PUJ)

2. Crossing of the iliac artery

3. Crossing of Vas deferens or broad ligament

4. Site of entry into the bladder

5. Ureteric Orifice

Clinical Features:

Pain –colicky type , radiating- mimics appendicitis,

cholecystitis, ovarian or tubal pathology.

Nausea , Vomiting etc.

Hematuria, dysuria, pyuria etc.

Tenderness in iliac fossa and renal angle.

Complications Of Ureteric Stones:

Obstruction

Hydronephrosis

Infection

Impaction

Ureteral Stricture

• Urine and blood tests

• Plain X-ray, KUB, IVU, CT- scanINVESTIGATIONS

• Conservative: Flush TherapyI.V Fluids, antibiotics, antispadmotic etc

• Surgical InterventionsTREATMENT

Surgical Intervention for UretericStones:INDICATION:

size of stone more than 6-8 mm.IVU showing deterioration of function.Co-existing infection or Impacted stones.

PROCEDURES:For stone in upper third ureter:

ESWL (ideal approach) URS- ureterorenoscopic stone removal Open Ureterolithotomy via loin incision

For Stones in middle third ureter URS

Open Ureterolithotomy

For Stones in lower third ureterURS

DORMIA BASKETING

Open ureterolithotomy

Ureteric meatotomy

Dormia Basketing : Basket is passed into the proximal

ureter beyond the stone and opened and then the stone is pulled out.

INDICATIONS:

stone in lower third ureter.Stone below pelvic brimsingle stone less than 1 cm in size

COMPLICATIONS:

Stone dislodgementurethral injury Avulsion of ureterStricture ureter

Classification

Adenoma: Benign counterpart of RCC

Tumours < 3 cm , rarely metastasize

Angiomyolipoma: Sporadic

Associated with tuberous sclerosis.(50%)

Oncocytoma: Benign,unifocal, 5-8cm average size

Difficult to differentiate from RCC

Wilm’s Tumor (Nephroblastoma)

PathologyGROSS:

smooth, soft,pinkish white in colourwith some haemorrhagic areas.

MICROSCOPICALLY:Mixture of primitive epithelial and

mesenchymal elements.

TYPES:

-FH (favourable histology)- without anaplastic

features.

-UnFH( Unfavourable histology)- with

anaplastic features.

Investigation & Staging Investigation:• Abdomen U/S, CT scan, MRI, X-ray (egg shell)

• IVU

• Renal angiography.

Staging:

Treatment:Unilateral tumours: Nephrectomy and

postoperative radiotherapy .

Bilateral tumours: Partial Nephrectomy

or Nephron Sparing surgery.

Chemotherapy : Actinomysin D,

doxorubicin etc.

Radiotherapy: preoperatively in inoperable

cases followed by surgery and chemo.

RENAL CELL CARCINOMAAlso known as Hypernephroma,

Grawitz tumour, Clear cell carcinoma, Internist tumour.

Most common neoplasm of the kidney.

3% of all adult malignancies.

Arrises from renal tubular cells.

Most common in 5th & 6th decades of life

Male:female ratio- 2:1

Etiology:6 Cs:Chronic cystic disease

Chromosomal defect

Cadmium exposure

Cigarette smoking

Coffee drinking

Congenital disease- (Von Hippel-Lindau disease)

Chronic dialysis & Diabetes are also a risk factor for RCC.

Classification:TYPE INCIDENCE GENETICS MAIN HISTOLOGY

Clear cell carcinoma

75% Familial and sporadic

Well differentiated,clear cytoplasm

Papillary 15% Familial and sporadic

Papillary pattern, psammoma bodies

Chromophobe RCC

5% Multiple chromosome losses, Hypodiploidy

Mixture of pale clear cells with perinuclearhalo and granular cells

Collecting duct of Bellini carcinoma

1% ---- Tubular and papillary pattern

PathologyGROSS:

o Commonly located in upper pole,

o Large, golden yellow, circumscribed

o Cut section- yellowish with areas of haemorrhage & necrosis.

MICROSCOPY:

o Malignant cells are cubical or polyhedral

o Histological types are-clear(75%),granular, spindle, sarcomatoid, papillary(15%)

METASTASIS OF RCCLOCAL: Into perinephric pad of fat,

calyces, renal pelvis.

LYMPHATIC: To hilar L.N, para-aortic L.N

BLOOD :

o To renal vein – as proliferating tumourthrombus

o To lungs – as cannon ball secondaries(50%)

o To bones (30%)

o To liver, brain, adrenal.

STAGING OF RCC

CLINICAL FEATURES OF RCC

Other manifestations include :

Pathological fractures

Anaemia

Hypertension

Liver Dysfustion

Endocrinal disturbances (rare)

Nephrotic Syndrome (rare)

INVESTIGATION:Urine Examination – for RBCs

Plain X-ray KUB

IVP – mass lesion & irregular filling defect.

USG

Contrast enhanced CT scan –Investigation of choice.

Renal angiography

MRI scan- asses the tumour thrombus in IVC

Venacavogram- asses the extent into IVC

Chest X-ray ,CT chest – shows cannon ball secondaries.

TREATMENTRadical Nephrectomy

Radical Nephrectomy with

extraction of tumour thrombus

Nephron sparing surgery

Therapeutic embolisation

Radiotherapy

Immunotherapy –interferon or

interleukin 2