Renal Stone, Ureteric Stone and Bladder

Stone

Dr. Hetal Nakrani

Assistant Prof.
Shalya Tantra Department

Department of Shalya Tantra

JSAM , Nadiad
Dr. Hetal Nakrani
• Stones can occurs
urogenital track in all
parts of (Urolithiasis)
–Kidney Stone
• Nephrolithiasis
–Ureteric stone
• Ureterolithiasis
–Bladder Stone
• cystolithiasis
–Urethral stones Dr. Hetal Nakrani
 Renal Stone
• Renal stone or calculus or lithiasis is
one of the most common disease of
the urinary track
• It occurs more frequently in the men
than in women and in whites than
black
• It is rare in children
• 90 % are radio opaque
Dr. Hetal Nakrani
• It shows a familial
predisposition
• Urinary calculus is a stone like
body composed of urinary salts
bound together by a colloid
matrix of organic materials
• It consist of a nucleus around
which concentric layers of
urinary salt are deposited
Dr. Hetal Nakrani
 Aetiology
1. Infection 6. Immobilisation
2. Hot climates 7. Decreased urinary citrate
3. Dietary factors 8. Urinary Stasis
4. Vit A deficiency /Inadequate urinary
5. Metabolic causes drainage
9. Randall's plaques
[Link]
Dr. Hetal Nakrani
1. Infection
Organisms such as Proteus, Pseudomonas, Klebsiella

produce recurrent UTI

organism produce the enzyme ureas

enzyme ureas splits area into ammonium and carbon dioxide
Ammonium renders the urine alkaline

which facilitates precipitation of phosphates

Triple phoshphates stones

Dr. Hetal Nakrani
2. Hot climates
• Hot climates cause dehydration resulting in production of highly
concentrated urine laden with of solutes, namely calcium and oxalate ,
which lead to formation of calcium oxalate stones.
3. Dietary factors
• Diet rich in red meat, fish, eggs can give rise to aciduria.
• Diet rich in calcium-tomatoes, milk, spinach, rhubarb produce calcium
oxalate stones.
[Link] A deficiency
• it causes epithelium desquamation dead cell from nidus – more
applicable for bladder stone
Dr. Hetal Nakrani
5. Metabolic causes
• Hyperparathyroidism increases serum calcium levels
resulting in hypercalcinosis and pelvic stones.
• Gout increases uric acid levels and causes multiple uric acid
stones.
6. Immobilisation:
• Prolonged immobilization causes decalcification of bones
and so hypercalciuria leading to stone formation
• Paraplegic patients secrète large amounts of calcium in the
urine resulting in calcium oxalate stones (they pass skeletons
in urine).
Dr. Hetal Nakrani
7. Decreased urinary citrate:
• Citric acid (300-900 mg/24 hours) keeps the urinary pH low.
When citric acid levels decrease, it promotes precipitation of
urinary calcium.
• Citrate level in urine maintains the calcium phosphate and
carbonate in soluble state and any decrease in citrate level
in urine causes stone formation
8. Urinary Stasis /Inadequate urinary drainage
• Urinary stasis due to resistance to urinary flow as in
anomalous kidney
• as in cases of horseshoe kidney, ectopic kidney are
increases the risk of infections
Dr. Hetal Nakraniand stone formation
9. Randall's plaques:
• Randall has suggested that initially a small erosion or
an ulcer develops at the tip of renal papilla on which
minute concretions or minor calcium particles get
deposited microlith -formation and give rise to stone
formation.
10. Cystinuria (Autosomal recessive). Cystine Stone

Dr. Hetal Nakrani

Dr. Hetal Nakrani
 Type of stone
•Primary stone
•Secondary stone

Dr. Hetal Nakrani

 Primary stone Secondary stone
Which appear in healthy Usually formed as a result of
urinary track microlith inflammation due to stasis,
infection, vit –A deficiency

originate in renal lymphatics Originate in pelvi-calcyceal

Randall’s plaque system
Acidic urine Alkaline urine

Dr. Hetal Nakrani

Primary stone Secondary stone
Oxalate calculus (ca ++ Phosphatic stone
oxalate) (Stone are mostly
Uric acid and urate composed of calcium
calculi ammonium-
Cystine stone
magnesium
Xanthine stone
phosphate)
Indigo stone
Mixed stone
Dr. Hetal Nakrani
 Oxalate calculus (ca ++ oxalate)
 Common type of stone (85 %
stone) among urinary stone
 Also called as mulberry stone
(resemble the mulberry fruit)
 It occurs in infected urine
 Oxalate stone is hard and single
 it is brown colour, with sharp
projection
 They are radio opaque so It is
visualized in plain X-ray KUB.
Dr. Hetal Nakrani
Mulberry stone

Dr. Hetal Nakrani

 Oxalate calculus (ca ++ oxalate)
 Their thorny surface cause bleeding due to injury to the
adjacent tissue
 Produces haematuria very early, resulting in deposition of
blood over the stone giving a dark color to the stone.
 On section it show wavy concentration laminae that
means it is formed by deposition of layers of calcium
oxalate on a nidus
 Show envelop crystal in urine
 Contains alternate layer of calcium and bacteria
vegetation.
 In infected urine the exist as mixed stones (calcium
Dr. Hetal Nakrani
oxalate calcium phosphate)
 Uric acid and urate calculi
• Comprise 5-10 % of all stones
• Hard, smooth
• Multiple, mutifaceted.
• Their colour varius from yellow to dark
browm
• Pure uric acid stones are radiolucent which
is uncommon
• Mostly also contain ca oxalate, • Contain
calcium oxalate which makes them opaque

Dr. Hetal Nakrani

• Occur in acidic urine
• Common in patients who
consume red meat
• They are seen in gout ,
hyperuricosuria, altered
purine metabolism
• Best responsive to
lithotripsy
Dr. Hetal Nakrani
 Cystine stone
• There are uncommon (1%)
• Present in patient with cystinuria
• Cystineuria is an inborn error of metabolism which
occurs due to decreased reabsorption of cystine
from the renal tubules.
• Increased excretion of cystine in urine results in
cystin calculus.
• Pink or yellow when first removed but they changes
to green on exposure to air.
• very hard.
Dr. Hetal Nakrani
 Cystine stone
• It is seen in young girl
• Radio-opaque due to sulphur .
• Cystine crystal which are found in urine in
cystinuria are usuallty hexagonal, white
and translucent
• This usually appear in acid urine

Dr. Hetal Nakrani

 Xanthine stone
• Very rare, due to altered xanthine
metabolism
• Smooth ,round, brick red in colour
• Patient with gout after allopurine
treatment
• Deficiency of xanthine oxidase
enzyme

Dr. Hetal Nakrani

 Indigo stone
• So uncommon that
are rarely academic
curiosities
• Blue in colour

Dr. Hetal Nakrani

 Phosphate stone
• Pure calcium phosphate stones are
rare and they are more in women
than in men
• Occurs usually as triple phosphate
(Calcium, magnesium and
ammonium phosphate )
• Enlarge rapidly in alkaline urine take
shape of pelvi- calyceal system
(staghorn)
usually occurring in an infected urine
Dr. Hetal Nakrani
 Phosphate stone
• This calculus produces
recurrent urinary tract
infection and haematuria and
slowly damages the renal
parenchyma
• Smooth and white in colour or
Dirty white to yellow in colour
• Symptoms are late
• Due to large size readily seen in
x-ray not due to density.
Dr. Hetal Nakrani
 Mixed stone
• Phosphate stone may occur as covering of a
primary stone
• Such stone are known as mixed stone

Dr. Hetal Nakrani

 Effect of stone
A. Same kidney
1. Obstruction
 A stone lodged at the
ureteropelvic junction or in
the ureter may cause
hydronephrosis if the
obstruction is intermittent
or incomplete
 When the obstruction is
complete it may slowly
destroy the kidney
Dr. Hetal Nakrani
2. Infection
 Infection due to stasis of urine
caused by the stone and due to its
presence as foreign body
 Such infection may cause pyelitis,
pyelonephritis, perinephric
adhesion and even perinephric
abcess
 When infection has been
superimposed on
hydronephrosis, pyonephrosis
Dr. Hetal Nakrani
may result
3. The epithelium of the pelvis and calyces in
relation to the stone gradually loses luster,
becomes rough and thickened . Parenchymal
ischamia may ne caused by local pressure
due to stone
4. Sometimes due to presence of stone the
lining epithelium of the renal pelvis may
undergo metaplasia which may instigate to
initiate malignancy of epidermoid nature
Dr. Hetal Nakrani
 Opposite kidney
• Compensatory hypertrophy may occur when
the affected kidney has lost function due to
complete obstruction with stone
• Stone formation may be bilateral
• Infection of the opposite kidney

Dr. Hetal Nakrani

 Clinical feature of Renal stone
• Pain
– Present in 80% case.
– Three type of pain are usually noticed viz.
• Fixed renal pain
• Ureteric colic
• Referred pain

Dr. Hetal Nakrani

 Renal pain
• Fixed renal angle pain – If the stone is free
and obstruction a calyx or ureteropelvic
junction, there will be dull flank pain due to
capsular and parenchymal distension
• Dull aching to pricking type of pain
posteriorly in the renal angle formed by the
sacrospinalis and 12th rib.
• this pain charecteristically get worse on
movement particularly walking up the
stairs and during jolting.

Dr. Hetal Nakrani

 Murphy's kidney punch test
• Murphy's kidney punch test
demonstrates tenderness at
renal angle. The same pain
may some times be felt
anteriorly in the costal
margin.
• Hence, it is described as
costovertebral pain.
Dr. Hetal Nakrani
renal angle formed by the sacrospinalis and 12th rib.
• Ureteric colic
When the stone is
impacted in the
pelviureteric junction or
anywhere in the ureter, it
results in severe colicky
pain originating at the loin
and radiating to the groin,
testicles, vulva and medial
side of the thigh.
This may be associated
with strangury. Dr. Hetal Nakrani
• The referred
pain is due to
irritation of the
genitofemoral
nerve

Dr. Hetal Nakrani

• Hydronephrosis :
sometimes
patient complains
of a lump in the
loin and a dull
ache, which are
due to HN caused
by renal stone
Dr. Hetal Nakrani
• Nausea and vomiting is due to intense sympathetic stimulation caused
by stretching of renal capsule mediated by coeliac plexus.
• Haematuria is common with renal stone because the majority of stones
are oxalate stones. The quantity of blood lost is small but it is fresh
blood . it is occur in small amount to make the urine durty or smoky
during and after an attack of pain
• Recurrent UTI:
 Fever with chills and rigors, burning micturition, pyuria may occur, along with
increased frequency of micturition.
• Guarding and rigidity of the back and abdominal muscles during
severe attack of pain.
• Incidental finding.

Dr. Hetal Nakrani

 P/A examination-
• Tenderness.— This is mostly present at the ‘renal
angle’ posteriorly
• Muscle rigidity over the kidney
• Swelling— When there is hydronephrosis or
pyonephrosis associated with renal calculus, a
swelling may be felt in the flank.

Dr. Hetal Nakrani

 Complications
• Calculous hydronephrosis
occurs due to back pressure producing renal enlargement.
Stretching of the renal capsule results in pain. In such cases, an
associated palpable kidney mass suggests hydronephrosis.
• Calculous pyonephrosis
Infected hydronephrosis where in the kidney is converted into a bag
of pus.
• Renal failure
 Bilateral staghorn stones may not be symptomatic until they
present with uraemia and renal failure.
• Squamous cell carcinoma
 Long-standing stones increase the risk of carcinoma.
Dr. Hetal Nakrani
 Investigation
1. Blood examination:
ESR, CBC, serum calcium, phosphate, Creatinine, blood urea,
uric acid,
 Blood urea and Creatinine to rule out renal failure.

Dr. Hetal Nakrani

 2. Urinalysis
Physical, Chemical, Microscopic, Bacteriological examination
 Physical examination may show smoky urine due to slight
haematuria or due to presence of pus
 Microscopic examination: urine may saw R.B.S , pus cells and cast .
Different crystal may be seen in the sediment to give a clue as to
the type of stone present
 Bacteriological examination of urine is highly important including
culture and sensitivity test

Dr. Hetal Nakrani

 3. Radiography
• Plain X-ray KUB:
–Before taking plain X-ray for KUB region
(both kidney, ureter, bladder) , the bowel
must be made empty by giving laxative
–At least 90% of renal stones are radio-opaque
and are easily visible in a plane film of KUB
region
–Enlarge renal shadow can be seen
Dr. Hetal Nakrani
Dr. Hetal Nakrani
Plain X-ray KUB showing bilateral Staghron calculus
Dr. Hetal Nakrani
• On lat. View it superimposed on shadow of vertebral
column.
• Following str. From shadow which appear like renal
stone
a. Lumbar or mesenteric . L.N. calcification
b. GB stone
c. FB. in GIT
d. Faecolith
e. Calcification lesion of kidney TB
f. Calcified adrenal gland

Dr. Hetal Nakrani

 4. USG
Presence of the stone can be diagnosis
Exact size and location of the stone can be evaluated

Dr. Hetal Nakrani

 5. IVU (Intravenous Urogram)
• To locate the stone accurately within the collecting
system of the kidney (pelvicalyceal system and the
ureter) and to assess the renal function
• A non radiopaque stone can be seen as a filling defect
• Hydronepgrosis and hydronepgroureterosis can be also
seen

Dr. Hetal Nakrani

6. CT Scan
7. Instrumental examination : Cystoscope
8. Examination of the stone
6. if stone is passed previously, crystallographic examination
is required in establishing the type of stone and cause of
stone formation

Dr. Hetal Nakrani

 Treatment
• The treatment of renal stones can be divided into
– Conservative (nonoperative) treatment
– Operative treatment.

Dr. Hetal Nakrani

 1. Conservative (Nonoperative) treatment
• Antibiotics to control infection
• antispasmodic , analgesic to relieve pain
• For remove of stone
–Hydrotherapy
–ESWL (Extracorporeal Shock Wave Lithotripsy)

Dr. Hetal Nakrani

 Hydrotherapy
– Small stone less than 5 mm in size passes out
spontaneously with forceful urine excreted by consuming
excessive water at times forced diuresis. Such treatment
known as hydrotheraphy
– Intravenous fluid(2-3 lit) is infused in a short period and
patient is advised to retain urine as possible , after that
20mg frusemide (Lasix) is intravenously injected.
– Due to forceful urination, stone which is less than 5 mm
passes easily through urethra
Dr. Hetal Nakrani
 ESWL
Extracorporeal Shock Wave Lithotripsy
• made by Dornier company in west Germany
• It is indicated when stone is < 2cm in size
• In this technique the stone is removed with
shock wave without the need for
instrumental penetration of the body
– Extracorporeal : from outside the body
– Shock Wave : pressure waves
– Lithotripsy : litho meaning stone and
tripsy meaning crushed
Dr. Hetal Nakrani
• There are three methods of shock generation,
– Electromagnatic
– Piezoelectric
– Electrohydraulic
• The lithotriptors depend on either ultrasound or
fluoroscopy for stone localization

Dr. Hetal Nakrani

• The treatment modality achieving stone fragmentation by
focusing externally generated shock waves on the target, i.e
stone within the renal collecting system through intact skin
and cross the body wall is called extracorporeal shockwave
lithotripsy
• The fragments which results after ESWL are passed via naturalis

Dr. Hetal Nakrani

• ESWL is done in situ when the
stone burden is less then 1cm and
cystoscopically placing a DJ stent
for larger stone burden
• The latter is necessary as when
large stones are treated, there can
be obstructive columnation of
stone fragments in the ureter
• The fragments which results after
ESWL are passed via naturalis
Dr. Hetal Nakrani
 Advantage

Can be done as an OP procedure

Less than 2.5 cm sized stone are well fragmented
Hard stone, oxalate stone are better eliminated by
ESWL
ESWL can be done repeatedly in different sitting

Dr. Hetal Nakrani

• Complication
 Renal haematoma
 Severe haematuria
 Injury to adjacement structure
 Fragmented stone remain in the ureter

• Contraindication
 Pregnancy
 Bleeding disorder
 Patient with anbdominal aneurysms
 Sepsis and renal failure

Dr. Hetal Nakrani

 II. Operative treatment
• Endoscopic procedures
• Open procedures
• Special situations

Dr. Hetal Nakrani

 Endoscopic procedures
PCNL (Percutaneous
nephrolithotomy)
• This is the most recent remedy for
kidney stone
• Stone are removed with the help
of nephroscope , without exploring
the kidney

Dr. Hetal Nakrani

 Endoscopic procedures
PCNL (Percutaneous
nephrolithotomy)
Indication
• Stone more than 2.5cm in
size
• Multiple stone
• Stone not responding for
ESWL
Dr. Hetal Nakrani
 PROCEDURE
• Initially cystoscopy is done and ureteric stent/ catheter is placed
and renal pelvicalyceal system is identified under C- Arm
guidance
• With a small I cm incision in the loin, the PCN needle is passed
into the loin to the renal cortex , into the pelvis of the kidney and
is confirmed by fluoroscopy.
• A guide wire is passed through the needle into the pelvis of the
kidney.
• The needle is withdrawn, with the guide wire left within the
pelvis.
• Dilators are passed over the guide wire and a working sheath is
introduced into the pelvis. Dr. Hetal Nakrani
Dr. Hetal Nakrani
• A nephroscope is passed into the pelvis
• Stone is visualized
• if the stone is small, it can be taken out.
• If it is big, it may have to be crushed
using ultrasonic or laser lithotripter and
the fragments are removed.
• Sometime balloon occlusion catheter
pass to prevent stone to pass into
Ureter.
• Aim of this procedure is to remove all
fragments of stone.
Dr. Hetal Nakrani
• Complication-
1. Haemorrhage – haemorrhage from the puncture renal parenchyma this
may be profuse and difficult to control
2. Perforation of collecting duct causing extravasation of irrigation fluid
3. Perforation of renal pelvis.
4. Colon injury.
5. Pleural injury.
6. Renal vein or artery injury

• Retrograde ureteroscopy & removal of stone (flexible ureteroscopy

available)

Dr. Hetal Nakrani

 Open surgery for stones
• Indication
1. Failure of ESWL/PCNL
2. C/I of ESWL/PCNL
3. Stones with other anatomical abnormality like PUJ obst. Calyceal
diverticulum
4. Multiple large stones
• Preoperative
– if urinary infection – antibiotics after C & S
– X-ray & IVP in view box in front of surgeon.

Dr. Hetal Nakrani

 Open surgical procedures
• Depending upon the location of the stone, various types of
procedures are done.
• They are as follows:
A. Pyelolithotomy
B. Nephrolithotomy
C. Extended pyelolithotomy
D. Pyelonephrolithotomy
E. Partial nephrectomy
F. Nephrectomy
Dr. Hetal Nakrani
 Pyelolithotomy
 Suitable for stones in extrarenal
pelvis.
 By loin (posterior subcostal) incision,
kidney is approached.
 Renal pelvis is opened, the stone is
removed
 The pelvis is closed. A drain is placed
and wound is closed.

Dr. Hetal Nakrani

 Nephrolithotomy
• When there is intrarenal
pelvis, the stone has to be
taken out through the kidney
parenchyma.
• By placing incision just
behind the most convex
surface , stone is removed

Dr. Hetal Nakrani

 Extended pyelolithotomy
• In case of intrarenal pelvis ,By
retracting the kidney
parenchyma of the collecting
system the incision over the
pelvis can be extended over
to the calyx and the stone can
be extracted from the calyx.
• Even a large staghom calculus
can thus be removed. Dr. Hetal Nakrani
 Pyelonephrolithotomy
• Stone is extracted
through an incision
in the pelvis as well
as the renal
parenchyma.

Dr. Hetal Nakrani

 Partial nephrectomy
• When the stone from a
lowermost calyx is
impacted and has
caused segmental
atrophy (scarring) a
lower pole
nephrectomy can be
done.
Dr. Hetal Nakrani
 Nephrectomy
• When the kidney is
destroyed by
pyonephrosis, following
obstruction by stone.
• Significant function loss
which is not expected
to recover even after
stone removal.
Dr. Hetal Nakrani
 Special situations
• Bilateral renal stones:
– Kidney with better function has to be operated first. 1-2 weeks later, the opposite
side can be operated. Except …………
1. Pain on one side suggest urinary obstruction
2. Pyonephrosis – tt first by nephrostomy
• Bilateral staghorn asymptomatic elder patient not to operate.
• If there is pyonephrosis with high grade fever, pain and tenderness,
– nephrostomy is done percutaneously under ultrasound guidance in which tube
drain is placed in the pelvis of the kidney for drainage of pus and urine. (PCN)
– Once the pus is cleared, fresh assessment of renal function is done.
– If the kidney is nonfunctioning, nephrectomy is done. If the kidney is functioning
ESWL/ PCNL/open procedure is done.
Dr. Hetal Nakrani
 Prevention of recurrence
• “I have remove stones GOD will care pt”
– False recurrence – during intervention, tiny fragments
may be left behind
– True recurrence- A patient with renal stone is usually
liable to produce further stone subsequently

Dr. Hetal Nakrani

 Identified Cause of recurrence
• Existing cause
– All stones should be investigated to exclude metabolic factors.
a. [Link] – hyperparathyroidism
b. S. uric – gout
c. Urinary urate , Calcium and phospate excretion in 24 hrs in urine.
d. Analysis of stone passed.
• Diatary advice
a. High fluid intake all time
b. important to keep urine dilute at night
• avoidance of milk, cheese and diet with high ca++
Dr. Hetal Nakrani
Uric acid stone-
– red meats, fish rich in purine avoided
– keep urine alkaline
– allopurinole- s. uric acid essential

Ca oxalate –
 strawberry , plums, spinach , rich in oxalats avoided
Dr. Hetal Nakrani
Cystine calculus – sulphur containing protein like egg,
meat, fish, restricted
 urine should kept dilute
 Penicillamine sometimes used.
Phosphate calculi-
 urine acidifier- Ammonium chloride

Dr. Hetal Nakrani

 URETERIC CALCULUS
Ureteral stone usually originated in the kidney
Stones come down from pelvis of the kidney
and may get impacted at any site of anatomical
narrowing of ureter
Gravity and peristalsis both contribute to
spontaneous passage into and down the ureter
Nature of stones are same as that of renal
stones.
90% single
Dr. Hetal Nakrani
Site
• Stones come down from pelvis of the kidney and
may get impacted at any site of anatomical
narrowing of ureter,
1. Pelvi ureteric junction
2. Where ureter crosses the iliac vessels
3. Where ureter cross the vas deferens
4. Where ureter penetrates outer layer of
bladder muscle
5. In the intramural portion of ureter near
the ureteric orifice
• Stone less than 5-8 mm size may pass
spontaneously
Dr. Hetal Nakrani
• When its enters round
or oval, arrested in its
descent to bladder and
becomes elogated

Dr. Hetal Nakrani

 Clinical Feature
 Ureteric colic
 Upper ureteric stone :
 Pain in the loin radiating to groin: Pain is severe, colicky, intolerable and
lasts for a few hours.
 Lower ureteric stone :
 When stone descends into lower ureter, pain radiates to the testicles, labia
majora and to the upper portion of thigh due to irritation of genitofemoral
nerve.
 Colic lasts for about 4-6 hours and is relieved by antispasmodics, narcotics
and NSAID.
 Nausea, vomiting, sweating due to pain and reflex pylorospasm.

Dr. Hetal Nakrani

An attack of haematuria , dysuria
 Frequency, strangury.
Tenderness in iliac fossa and renal angle
 Guarding and rigidity of the abdominal wall
if present on the right side, is confused with acute
appendicitis.

Dr. Hetal Nakrani

 P/A examination
• Tenderness and rigidity over some part of ureteric
course
• Rarely VUJ stone felt on rectal or vaginal
examination
• On Rt. Side difficulty to differentiated from
appendicitis or inflamed appendix tip lying over
ureter can give rise RBC in urine.
Dr. Hetal Nakrani
 Pathology
Ulceration at site of impaction and fibrosis- stricture
Diverticulum.
Perforation & fistula rare
Hydroureter ,hydronephrosis
Non functioning of kidney due to pyonephrosis or
pyelonephritis.

Dr. Hetal Nakrani

 Investigation
 Urine—microscopy, C/S.
 Plain X-ray, KUB—radio-opaque stones are visible in 90% of cases—in the
line of ureter (near the tips of transverse processes of lumbar vertebrae,
sacroiliac joint and medial to ischial spine).
 Lateral or oblique films are required to differentiate from other opacities
which mimic stone.
 IVU shows hydronephrosis and hydroureter.
 Function may be accurately assessed by isotope renogram.
 Blood urea, serum creatinine, serum calcium, uric acid level.
 U/S is useful.
 CT scan .

Dr. Hetal Nakrani

 Treatment
• Plenty of water orally.
• Diuretic—oral frusemide to flush the stone.
• Suitable antibiotics to control sepsis; antispasmodics to
relieve pain.
• IV fluids—fast infusion of about 1.5 to 2 liters and
injection frusemide 60 to 80 mg. Usually given for 3 to 5
days.
• Surgical intervention for ureteric stones:
Dr. Hetal Nakrani
• Removal of stone
–Indication
• Repeated colic
• Enlarging stone and no descent
• Complete obst. Or in HN +HU
• Sec. infection not clear by antibiotic

Dr. Hetal Nakrani

 Stone in Upper third ureter
 Flush therapy
 ESWL
 The stone is pushed into the renal pelvis and then
PCNL is done.
 URS—Ureterorenoscopic stone removal:
 Through ureteroscope, stone is visualised and often
fragmented using pneumatic bombarder. It is then
extracted by ureteroscope.
 Complications are perforation of ureter and
extraperitoneal leakage of urine, bleeding.
 Open ureterolithotomy through loin incision
Dr. Hetal Nakrani
Stone in middle third ureter
• Flush
• URS
• Open
Ureterolithotomy

Dr. Hetal Nakrani

Stone in lower third ureter
Flush therapy
URS
 Dormia Basketing
Open Ureterolithotomy.
Ureteric Meatotomy
 Using cystoscope under general anaesthesia,
ureteric meatotomy is done for stones impacted
at the ureteric orifice. It is released by cutting
the orifice at upper and lateral aspects.

Dr. Hetal Nakrani

Dormia
Basketing
• Basket is passed into
the proximal ureter
beyond the stone and
opened. The stone is
then pulled out.

Dr. Hetal Nakrani

 Vesical calculus
• Incidence
Vesical calculus was quite common previously in the 19th
century
Gradually its incidence has come down particularly in
children and adolescents
This seems to be due to improved diet rich in protein and
abolition of malnutrition

Dr. Hetal Nakrani

• Bladder stone comprise 5%of
urinary tract stones
• It usually remain free in the
bladder and moves according
to the position of the patient
• It gravitates of the most
dependent part which is neck
of the bladder in erect posture
and behind the interureteric
ridge in recumbent position
Dr. Hetal Nakrani
 Type
• Two type of vesical calculi are found
• Primary vesical calculus,
– which develops in the sterile urine and mostly originates in the kidney
which passes through the ureter into bladder . Here it becomes enlarged.
– It is usually oxalate stone
• Secondary vesical calculus,
– Stone develops in the presence of infection and stasis due to obstruction
to the urinary flow
– This type of calculus mostly originates in the bladder
– It is usually phosphate stone
– In this group may be included another type of vesical calculus which
occurs by deposition of [Link] upon a foreign body in the bladder
Hetal Nakrani
 Composition of vesical stone
• According to Kidney Stone

Dr. Hetal Nakrani

 Clinical features
Males are common affected in the ratio
of 8:1
Asymptomatic : vesical calculus remains
asymtomatic for quite a long time when
these lies in the diverticulum of the
bladder or in the post prostatic pouch .
This calculi are revealed on radiological
examination for another reason

Dr. Hetal Nakrani

Frequency
o It is more during day than night,
because during day, due to
ambulation stone comes in contact
with the trigone of the bladder and
irritates , whereas during night, stone
slips towards the funds, away from
the trigone and so less frequency and
pain
o Frequency of micturition is the
earliest symptom of bladder stone. It
is due to cystitis.
Dr. Hetal Nakrani
• Pain:
o More during day which is at the
end of micturition referred to tip of
penis or labia
o Also increase during jolting
movement .
o Suprapubic pain and tenderness
may be present
o Pain is decreased on lying down
because stone falls away from the
trigone of the bladder.

Dr. Hetal Nakrani

• Haematuria :
• Haematuria, is due to stone causing abrasions in the bladder
mucosa.
• Interruption of urinary stream and often acute urinary
retension
• Features of cystitis: burning micturation, fever, pain
• P/R or P/V : large stone may be palpable
• Stone may be identified incidentally in plain x- ray, KUB, or
U/S

Dr. Hetal Nakrani

 INVESTIGATION
• Urine microscopic :
 Envelope crustal in oxalate stone
 Hexagonal type in cystine stone
 Red blood cells may be present-microscopic haematuria
• Urine C/S
• Blood urea, serum creatinine, serum calcium, inorganic phosphate, uric acid
• Plain X-ray, KUB shows radio- opaque stone – 90% are radio-opaque
• IVU to see the function of kidney
• Cystoscopy to see radioluscent stone
• U/S abdomen

Dr. Hetal Nakrani

Dr. Hetal Nakrani
 Treatment
 In majority of cases surgery is required to remove the stone unless the
stone is very small
 which may be passed out spontaneously with the urine or may be
removed by means of an evaculator after passing the largest size
cannula through the urethra
 Vesical calculus is removed by
1. Cystoscopic litholapaxy
2. Suprapubic open cystolithotomy
3. Suprapubic percutaneous litholoplaxy

Dr. Hetal Nakrani

 1. Cystoscopic litholapaxy
• Under GA cystoscope is passed and the stone is visualised
• It is fragmented by laser, electromagnetic waves or mechanohydraulic lithotripsy
• The bladder is flushed using an irrigator

• Contraindication
o Too large stone
o Too small stone. Too soft, too mach stone
o Stone in bladder diverticula
o Bladder tumour
o Contracted bladder
o Patient age below 10 years
o When patient general condition poor, as the procedure takes a longer duration it is avoided and
open removal is advised

Dr. Hetal Nakrani

Dr. Hetal Nakrani
 2. Suprapubic open cystolithotomy
• Through pfannenstiel incision, bladder is approached
extraperitoneally.
• Bladder is identified by its detrusor muscle pattern, which is criss
cross and also its venous pattern
• Bladder is opened near the fundus and stone is removed
• Bladder is closed often with SPC using malecot’s catheter and
foley’s catheter is passed per urethra
• Wound is closed on layer with drain

Dr. Hetal Nakrani

Dr. Hetal Nakrani
 3. Suprapubic percutaneous lithaloplaxy
• This procedure is becoming popular
• When cystoscope cannot be passed per urethra,
bladder is approached suprapubically
• Through a needle, guidewire and dilators, a track is
created through which a nephroscope is passed to
remove the stone after fragmenting

Dr. Hetal Nakrani