Edited by:

Kamrul Islam Shipo

The urinary tract includes the kidneys, ureters, bladder and urethra. Within each kidney, urine flows from the outer cortex to the inner medulla.

The renal pelvis is the funnel through which urine exits the kidney and enters the ureter.

The kidneys remove wastes, control the body's fluid

balance, and regulate the balance of electrolytes

The medulla is composed of a series of conical

masses called the renal pyramids.

The apex of these pyramids form a papilla which

projects into the lumen of the minor calyces.

The cortex extends between these medullary

pyramids as the renal columns

The minor calyces are cup shaped tubes which

surround the renal papilla. These converge to form

the major calyces, which in turn unite to form the

renal pelvis.

The stones are solid concretions or calculi (crystalaggregations) formed in the kidneys from dissolved urinary minerals

Stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase

Urinary calculi are more common in men than in women.

Incidence of urinary calculi peaks between the 3rd and 5th decades of life.

There is seasonal variation with stone occurring more often in the summer months suspecting the role of dehydration in this process

1)Dietetic. (more calcium oxalate containing food)

2)Altered urinary solutes and colloids:(reduced water intake=increased solid deposition >increased crystallization >stone formation.)

3)Reduced urinary citrate .

4)Renal infection.

5)Inadequate water drainage and urinary stasis.

6)Prolonged immobilization.

7)Hyperparathyroidism .(increased calcium deposition .)

8)Gout.

Calcium oxalate

Calcium phosphate

Mixed-Oxalate+Phoaphate

Struvite (Ca, Al, Mg, Phosphate)

Cystine

Xanthine

Matrix

sharp, severe pain

most characteristic manifestation of renal or ureteral calculi

caused by movement of the calculus and consequent irritation

Renal colic originates deep in the lumbar region and radiates around the side and down toward the testicle in the male and the bladder in the female

Ureteral colic radiates toward the genitalia and thigh

When the pain is severe, the patient usually has nausea, vomiting, pallor, grunting respirations, elevated blood pressure and pulse, diaphoresis, and anxiety

Urinary tract infection

Other manifestations of calculi include infection with an elevated temperature and white blood cell (WBC) count and urine obstruction that causes hydroureter, hydronephrosis, or both

Haematuria

Pain resulting from the passage of a calculus down the ureter is intense and collicky.

1. Assessment

Prior stone formation

Renal or bladder colic type pain without objective evidence of calculi formation

Risk factors

Location, character, and duration of current pain

Current and previous radiation patterns (indicates possible location and movement of calculus through the urinary system)

#G/E:

Anemia

Oedema

Dehydration

Increased Pulse and BP.

Raised Temperature.

#Urinary System:

Tenderness on palpation

Passage of stones.

1.Plain x-Ray of KUB region( radio dense shadow)

2.Ultrasonography of KUB region(echogenic structure with shadow)

3.Intravenous urography .

4.Intravenous pyelography .

5.Excretory urography .

6.Unenhanced computer tomography

7.Plain radiograph of the abdomen

Nowadays Unenhanced computer tomography Has been seen more sensitive and specific. It can identify both radioluscent and radio opaque shadow.

90% of the urinary stone is radio opaque .

10% gal bladder stone is radio opaque.

Uric acid stone , Cystine,struvite stones are radioluscent .

#Others :

-Urine RME and C/s

-Serum creatinine

#For Anaesthesia :

>CBC

> RBS

>CX-R

>ECG

# To indentify the cause:

Serum calcium

PTH

Uric acid Urinary calcium Phosphate

Obstructive uropathy compromises the function of the affected kidney.

Microscopic or gross hematuria is rarely associated with significant hemorrhage.

Urosepsis is infection that may cause shock or death without prompt intervention.

Ileus may occur

Stones<5mm,90 percent spontaneous passage.

Hydration

Diuretics

Anti-emetics

involves first visualizing the stone and then destroying it.

Access to the stone is accomplished by inserting a ureteroscope into the ureter and then inserting a laser, electrohydraulic lithotriptor, or ultrasound device through the ureteroscope to fragment and remove the stones.

A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent.

Hospital stays are generally brief, and some patients can be treated as outpatients.

LASER LITHOTRIPSY. A newer treatment for calculi is laser lithotripsy. Lasers are used together with a uretero-scope to remove or loosen impacted stones. Constant water irrigation of the ureter is required to dissipate the heat

ESWL is a noninvasive procedure used to break up stones in the calyx of the kidney.

In ESWL, a high-energy amplitude of pressure, or shock wave, is generated by the abrupt release of energy and transmitted through water and soft tissues. When the shock wave encounters a substance of different intensity (a renal stone), a compression wave causes the surface of the stone to fragment. Repeated shock waves focused on the stone eventually reduce it to many small pieces.

These small pieces are excreted inthe urine, usually without difficulty.the fragments may be passed upto 3 months after the procedure

Stone size should be 1.5-2 cm

Percutaneous lithotripsy involves the insertion of a guide percutaneously (through the skin) under fluoroscopy near the area of the stone. An ultrasonic wave is aimed at the stone to break it into fragments.

stone size should be >2.5 cm

IMMEDIATE

Pain

Urinary infection

Obstructive uropathy

Haematuria

Urinoma-URINOMA HAPPENS AS A RESULT OF URETERAL

TEAR WHICH ALLOWS THE ENTRY OF FREE FLUID INTO THE

RETROPERITONEUM

Renal and perirenal haematoma

Surrounding organ injury

DELAYED

Renal functional loss

Hypertension

Residual calculi

Recurrent calculi

If the stone is too large or lithotripsy procedures fail to remove it, an open surgical procedure is performed

Cystolithotomy, removal of bladder calculi through a suprapubic incision, is used only when stones cannot be crushed and removed transurethrally. Stricture (abnormal narrowing) is the most common postoperative complication.

A stone is removed from the renal pelvis by pyelo-lithotomy and from the renal calyx by a nephrolithotomy

Despite advances in the treatment of urinary calculi, it is often impossible to remove all stone fragments completely. From 5 to 30 percent of patients have residual stone burden requiring ongoing treatment.

Recurrence rate is approximately 30 percent within years.

Extracorporeal shock wave lithotripsy and endoscopic stone removal techniques have significantly improved long term prognosis of renal function after calculus removal.