Very valuable PPT for surgical disciplines faculty, Resisents and MBBS Students

1. RENAL CALCULI
Dr Anil Kumar
Assistant Professor
Department of Surgical Disciplines
All India Institute of Medical Sciences, Patna

2. OBJECTIVE
• Anatomy of Kidney
• Causes of Renal Stones
• Types of Renal Stones
• Management of Renal Stones.
• ESWL, PCNL & Operative concept in Brief.

3. ANATOMY
• Length – 10 to 13 cm
• Width- 5 to 7.5 cm
• Thickness- 2 to 2.5 cm
• Weight – 150 to 175 gram
• Left kidney( larger ) > Right kidney

4. ANATOMY:
• Right Kidney: Lower than Left
• From anterior to Posterior: VAU.
• Right Renal Artery crosses posterior to
the IVC.
• Left Renal Vein is longer than Right.

5. Esophagus (cut)
Inferior vena cava
Adrenal gland
Hepatic veins (cut)
Renal artery
Renal hilum
Renal vein
Iliac crest
Kidney
Ureter
Urinary
bladder
Urethra
Aorta
Rectum (cut)
Uterus (part
of female
reproductive
system)
Right Renal Vein( No
Tributaries) – IVC
Left Renal vein
Receive tributaries
from- Left Adrenal ,
Gonadal, Phrenic &
Lumbar.

6. Aorta
Renal artery
Segmental artery
Interlobar artery
Arcuate artery
Cortical radiate artery
Afferent arteriole
Glomerulus (capillaries)
Nephron-associated blood vessels
Inferior vena cava
Renal vein
Interlobar vein
Arcuate vein
Cortical radiate
vein
Peritubular
capillaries
and vasa recta
Efferent arteriole
Path of blood flow through renal blood vessels

7. Cortical radiate vein
Cortical radiate artery
Arcuate vein
Arcuate artery
Interlobar vein
Interlobar artery
Segmental arteries
Renal artery
Renal vein
Renal medulla
Renal cortex
Frontal section illustrating major blood vessels

8. Renal cortex
Renal medulla
Major calyx
Papilla of
pyramid
Renal pelvis
Ureter
Minor calyx
Renal column
Renal pyramid
in renal medulla
Fibrous capsule
Renal
hilum
(a) Photograph of right kidney, frontal section (b) Diagrammatic view

9. Ureter
Trigone
Peritoneum
Rugae
Detrusor
muscle
Bladder neck
Internal urethral
sphincter
External urethral
sphincter
Urethra
External urethral
orifice
Ureteric orifices
Female

10. Ureter
Trigone of bladder
Prostate
Membranous urethra
Prostatic urethra
Peritoneum
Rugae
Detrusor muscle
Bladder neck
Internal urethral sphincter
External urethral sphincter
Spongy urethra
Ureteric orifices
Male The long male urethra has three
regions: prostatic, membranous and spongy.
External urethral orifice

11. KIDNEY: RELATIONS
Anterior Relation
Posterior Relation

12. RISK FACTORS
IMMOBILITY
SEDENTARY LIFE
STYLE
DEHYDRATION
METABOLIC
DISTURBANCES
H/o OF
RENAL
CALCULI

13. RISK FACTORS
HIGH MINERAL CONTENT IN DRINKING
WATER
UTI & H/O FEMALE GENITAL
MUTILATION
PROLONGED INDWELLING
CATHETERISATION
NEUROGENIC BLADDER

14. CAUSES: RENAL CALCULI
• Vitamin A Deficiency- Desquamation of epithelium- Nidus for Stone.
• Dehydration- Raise the Urinary Solutes- Promote the Precipitation.
• Reduction of Urinary Colloids: Colloids adsorb solutes & chelate calcium.
• Decreased Urinary Citrate: Normal range- 300 to 900 mg /24 hr. This level maintain
the Ca3(po4)2 & CaCo3 in soluble state.

15. CAUSES: RENAL CALCULI
• Renal Infections: Urea splitting Streptococci , Staphylococci , E. Coli & Proteus.
• Inadequate Urinary Drainage & Urinary Stasis.
• Prolonged immobilization: Skeletal decalcification- Urinary Ca++ - Calcium
Phosphate calculi.
• Hyperparathyroidism( Parathyroid adenoma) : Hypercalcemia & Hypercalciuria-
Renal calculi( Recurrent or Multiple stone)
- These patients ‘ pass their skeletons in their urine’

16. ETIOLOGY

17. RANDALL’S PLAQUE
Soft tissue calcification found
in the deep renal medulla-
skirting the surface of the
epithelium of the Papilla,
where they act as nucleating
elements for renal stones

18. PATHOPHYSIOLOGY
•Slow urine flow, resulting in supersaturation of
the urine with the particular element that first
become crystallized and later become stone

19. PATHOPHYSIOLOGY
•Damage to the lining of the urinary tract

20. PATHOPHYSIOLOGY
•Decreased inhibitor substances in the urine that
would otherwise prevent supersaturation and
crystalline aggregation

21. STONES:
Primary Stones
In healthy urinary tract without
any antecedent inflammation.
Formed in acid urine.
Usually consist of calcium
oxalate, uric acid, urates,
Cystine, xanthine or calcium
carbonate.
Secondary Stones
Are usually formed as the
result of inflammation.
Urine is usually alkaline as
urea splitting organism are
most often the causative
organisms.
e.g Triple phosphates
stones

22. TYPES OF RENAL STONES
• Calcium oxalate – Mc Type
• Phosphate stone
• Uric acid
• Xanthine
• Cysteine

23. TYPES OF RENAL CALCULUS:
• Calcium Oxalate: MC type of Kidney stone(85%)
• Also called as Mulberry stone
• Shape: Irregular, Hard surface with
sharp projection
• Colour: Brown
• Risk Factors: Hypercalciuria , Hypercalcemia
& Hyperoxaluria.
• Radio dense stone

24. PHOSPHATE CALCULUS:
• Also k/as : Struvite stone .
• Composition: Calcium, Ammonium & Magnesium Phosphate
( Triple Phosphate stone)
• Risk factors: Alkaline urine with Proteus Infection (Infectious stone)
• Surface: Smooth and Dirty white in colour.
• Calculus may enlarge – Fill whole of the collecting system- Staghorn Calculi.

25. PHOSPHATE CALCULUS
• Staghorn Calculi: Usually silent and
may cause progressive destruction
of renal parenchyma.
• Predisposing Factors:
-Women ( More incidence of UTI)
-Foreign Body in the Urinary tract
(Foley’s Catheter)
-Neurogenic Bladder
-BOO.
• Over 10 years of follow up: Incidence of recurrence & UTI is up to 50%

26. URIC ACID STONE
• MC Radiolucent urinary calculi
• Formed in Acidic Urine.
• Hard in consistency, Smooth surface
• Appearance: Multifaceted, Irregular or Rosettes
• Colour: Yellow to reddish brown.
• Diagnosis: Filling defect on excretory Urogram.

27. URIC ACID STONE
• Filling defect on X-Ray- Confirmed by CT Scan.
• Predisposing Factors for Uric Stones
-Gout
-Myeloproliferative disease
-Lesch- Nehan Syndrome.
• Treatment Approach: Low purine diet,
Hydration & Alkalization of urine
-Allopurinol
-Acetazolamide( If PH is < 6.5)

28. CYSTINE CALCULUS:
• Extremely Hard stone
• Found only in Acidic Urine
• Appearance: Hexagonal or Benzene ring
• Predisposing Factors: Cystinuria.
• Treatment Approach: Low methionine diet
-Alkalization of urine
-Cystine complex agent: D-Penicillamine, Alpha-mercaptopropionylglycine(MPG)
Radio-opaque

29. XANTHINE CALCULUS:
• Seen in Xanthinuria
• Extremely Rare stone
• Appearance : Smooth( surface) & Round
• Colour: Brick red
• Cross section: Lamellation.
• High fluid intake with Allopurinol:
(Treatment Approach)
Radiolucent Stone Like
Uric acid

30. CLINICAL FEATURES
• Age: 30-50 years
• Gender: More common in Male( M:F = 4:3)
• Infectious stone – More common in female.
• MC Symptom- Pain ( 75%)
• Haematuria ( calcium oxalate)- Very minimal
• Pyuria.

31. PAIN IN RENAL CALCULI
• Fixed renal pain ( Renal angle)/ Hypochondrium.
• Nature: Excruciating & Cramping Pain.
• Radiation: Along the course of Ureter.( Groin, Penis, Scrotum or labium)
• Severity of pain is not related to the size of stone.
• Pain may be worse on movement( climbing stairs)
• Pain last for less than 8 hours ( In the absence of infection)

32. PAIN IN RENAL CALCULI:
• Pain is almost invariably associated with Hematuria.
• Tachycardia ( Because of pain )
• Rigidity of the Lateral abdominal muscle.
• Tenderness on deep palpation.
• Percussion over kidney: Sudden, sharp & severe pain ( stab like)

33. CLINICAL FEATURES OF RENAL STONE
• Hematuria: minimal
• Pyuria: Renal Stone Infection pressure builds up in dilated
with obstruction collecting system
Septicemia Organism injected into the Circulation

34. DIETL’S CRISIS( INTERMITTENT HDN)
Acute
Renal
Pain
After some
hours
Large volume of
urine is Passed
Pain is
relieved

35. INVESTIGATION: RENAL STONE
• URINE: pH , Microscopic examination( RBC, PUS CELLS & CRYSTALLURIA) & Culture for urea
splitting organism
• Acidic Urine: CCU ( Calcium Oxalate, Cystine & Uric Acid)
• Alkaline Urine: Calcium Phosphate ( Brushite) & Struvite.
• Crystalluria: Calcium oxalate Monohydrate- Dumbbell or Hourglass Appearance
• Struvite – Coffin lid. Uric Acid- Multifaceted, irregular or rosettes
• Cystine- Hexagonal or benzene ring

36. INVESTIGATION: RENAL STONE
• Renal Function Test: Blood urea & Serum Creatinine.
• S . Uric acid level.
• Haemogram.
• Coagulation Profile
• Blood Sugar

37. X-RAY KUB: RENAL STONE
• Kidney stone – looked opposite to second lumbar vertebrae( L2)
• Lateral X-Ray of Abdomen: Gall stones – Anterior to Lumbar spine and renal and
ureteric calculus overlie the lumbar spine.
• 90 % of stones are Radiopaque.
• Radiolucent stones are TIXU: Triamterene ( Antihypertensive drug), Indinavir
(Protease inhibitors) , Xanthine & Uric acid stone.

38. OPACITIES ON PLAIN X-RAY :
CONFUSED WITH RENAL CALCULUS
Calcification of ATM-V
Adrenal Gland
Tuberculous lesion in the kidney
Mesenteric Lymph node
Walls of the Veins ( Pelvis)- Phlebolith
GOAT
Gall stones
Ossified tip of the 12th Rib
Concretion in the Appendix
Tab / Foreign bodies in the alimentary
canal(Cyclopenthiazide)/ Navidrex

39. X-RAY : RENAL STONE

40. USG: SCREENING TOOL FOR RENAL
CALCULUS.
Posterior acoustic shadow Multiple renal stone:

41. IVP:INTRAVENOUS PYELOGRAM
• is an x-ray examination of the kidneys,
ureters and urinary bladder that uses
iodinated contrast material injected
into veins.
Immediately- Renal Blush of cortex area
At 3 minutes- Diminished renal blush with
Delineation of calyces and renal pelvis
At 9-15 minutes – Contrast emptied into
Ureter & bladder.

42. IVP: EARLY FILM ( 1 MIN & 5 MIN) & DELAYED
FILM
Non-
functioning left
kidney

43. NON-CONTRAST CT : MOST SENSITIVE
INVESTIGATION

44. NON-CONTRAST CT : MOST SENSITIVE
INVESTIGATION

45. RETROGRADE PYELOGRAM:
• Dye is injected directly into the ureter rather than into vein.
• Better delineation of anatomy of Kidney & Ureter.
• Very useful if distal ureter is not visualized.
• Exclude ureteric calculi and allow assessment of ureteric stricture.
• Cystoscopy with RP: Detect most of the pathology.

46. RETROGRADE PYELOGRAM
Cystoscopy

47. RADIONUCLIDE EVALUATION:
• DMSA ( Dimercaptosuccinic acid): Renal Morphology( Scarring )
First inject the DMSA into vein that enter- Kidney
second ( after 2-4 hours) Take image by
gamma camera
• DTPA( Diethylene Triamine Pentacetic Acid):
Assess Perfusion & Function
Less effective than MAG-3
• MAG-3 ( Mercapto-acetyl glycine ): Best for Renal
Perfusion.
DMSA

48. DTPA:

49. MAG-3: OBSTRUCTED LEFT KIDNEY
MAG3 -
demonstrated the
obstructed left
kidney at the level of
the ureteropelvic
junction with
28ml/min
renographic
clearance, which
represented 38% of
the total renal
function.

50. MANAGEMENT OF RENAL CALCULUS
• Conservative Treatment(4-6 weeks): Indication
• Single stone < 5 mm.
• Ureter is undilated.
• Stone in lower third of ureter.
• Evidence of downward movement.
• Fluid intake : Most important as well as first
step

51. MANAGEMENT OF RENAL CALCULUS:
CONSERVATIVE
• For Cystine, Calcium oxalate & Uric acid stone
• Increase fluid Intake
• Alkalization of Urine: Potassium citrate/ Sodium bicarbonate
• Urinary PH: 6.5-7.0
• For Uric Acid: Allopurinol 300 mg QID
• For Cystine: D-Penicillamine & Alpha – Mercaptopropionyleglycine

52. RENAL CALCULUS
• Avoid animal protein: Meat, chicken & Egg
• Take low salt diet.
• High Fibre diet
• Weight Reduction.
• Tamsulosin- alpha -1 blockers ( Flowmax) : 0.4 mg for 7-10 days:
• Nifedipine: CCB: May be beneficial.

53. SURGICAL INTERVENTION: RENAL
CALCULUS
• ESWL ( Extracorporeal Shock Wave Lithotripsy)
• PCNL ( Percutaneous Nephrolithotomy)
• URS ( Ureteroscopy)
• Lap Stone Removal
• OSS ( Open Stone Surgery)
OSS: Indication:
1.Anatomical abnormality(PUJO)
2. Non functioning kidney with stone
( Nephrectomy)
Types:
1. Pyelolithotomy
2.Extended Pyelolithotomy
3. Nephrolithotomy
4.Partial Nephrectomy

54. STONE & SURGERY OF CHOICE
• Stone < 2 cm: ESWL
• Stone > 2 cm : PCNL
• Staghorn Calculi: PCNL + ESWL
• Initial approach is PCNL , followed by ESWL.
• 80-85% of simple renal calculi : Treated satisfactorily with ESWL.

55. ESWL:
• Principle: Bombarding of stones with High energy shock waves to disintegrate the
stones into fragments- small fragments pass down to ureter.
• Localization of stone for bombarding – Fluoroscopy or USG
• Physics of ESWL: The change in density b/w the soft renal tissue & hard stone
causes release of energy at the stone surface which causes “ Compression induced
tensile cracking of stone“.
• Incoming Shock waves – causes fragmentation of stones- Erosion & Shattering
• Gold standard / strongest Lithotripter for ESWL- Dornier Unmodified HM-3

56. POSITION OF THE PATIENT CHECKED
BY USG

57. PATIENT ON LITHOTRIPTER: ESWL

58. EROSION & SHATTERING OF ESWL WAVES

59. SHOCK WAVES OF ESWL:
Small fragmented stones:
Shock waves breaking the
stones

60. ESWL

61. CONDITION WHERE ESWL MAY FAIL:
• Stone size > 2 cm, Multiple stone or Staghorn stone.
• Lower Calyceal location
• Marked hydronephrosis or scarring
• Calyceal diverticulum
• Horseshoe kidney
• Difficult stone : Brushite, Hydroxyapatite, Cystine & Calcium oxalate monohydrate (
BHC-2)

62. CONTRAINDICATION OF ESWL:
Absolute Relative Relative
Pregnancy UTI Obesity
Bleeding Disorder Unrelieved distal obstruction Severe Renal failure
Cardiac Pacemakers Aneurysm
Uncontrolled Hypertension
Severe orthopedic deformity

63. COMPLICATIONS OF ESWL:
• Infection – Main complication.
• Acute injury to the renal parenchyma: Hematuria & edema around the kidney.
• Chronic renal injury: Hypertension, Decrease renal function & Increase in rate of
stone recurrence.
• Lung Parenchymal Injury
• Steinstrasse ( street of stones gravel in ureter)

64. PCNL: PERCUTANEOUS
NEPHROLITHOTOMY
• Indication:
(a) Size of stone > 2.5 cm
( b) Multiple stones
(c) Stones not responding to ESWL ( BHC-2 )
(d) Central part of staghorn stone.

65. PCNL : STEPS
G/A or Regional Anesthesia
Cystoscopy & Ureteral catheterization
Instillation of radio-opaque dye to
opacify the renal pelvic-caliceal system .
Puncture site: few centimeter inferior &
medial to tip of the 12th ribs

66. PCNL :
Hollow Needle is
placed from skin to
opacity of renal
pelvic caliceal system

67. PCNL
Wire is inserted
through the hollow
needle – to guide the
passage of a series of
dilators

68. PCNL
Gradual dilatation of the
track - so that
Nephroscope can be eaisly
inserted through the
dilated track

69. PCNL: Nephroscope inserted into the track

70. PCNL
• Small stones : may be grasped under vision & extracted whole
• Larger stones:
Fragmented by USG,
Laser or electrohydraulic
Probe and removed in
Pieces.

71. PCNL
Put a Nephrostomy
tube in the pelvic
caliceal sytem- to
remove all the
remaining stone
subsequently

72. COMPLICATION OF PCNL
• Hemorrhage
• Perforation of the collecting system
• Perforation of the colon
• Perforation of the pleura
• Infections

73. OSS:RENAL CALCULUS
Positioning & Incision.

74. PYELOLITHOTOMY
Kidney –Mobilized & Vascular
Pedicle control
On the Pelvis: Give Longitudinal
incision over the stone

75. EXTENDED PYELOLITHOTOMY
Indication:
Large Staghorn
Calculi & Calyceal
Stone

76. NEPHROLITHOTOMY:
• Indication: Complex calculus branching into the most peripheral calyces.
• Mobilized the kidney.
• Cross-clamp the renal pedicle to control the bleeding.
• Cool the kidney with ice pack( to increase the ischemic time)
• Incision given on Brodel’s Line: Posterior & parallel to the most convex part of the
kidney , where territories of the anterior and posterior branches of the renal artery
meet.

77. NEPHROLITHOTOMY
Brodel’s
line
Stone

78. PARTIAL NEPHRECTOMY:
Indication:
• Stone in lowermost calyx
• Kidney containing stone area:
Nonfunctional.
• Xanthogranulomatous pyelonephritis.

79. LlllllllllLaparoscopic stone
removal

80. Thank
Y
O
U