Granular
Oval
Acicular
Radial
Muriform
Coraliform
Urinary lithiasis classification
Coraliform lithiasis classification (Proca E, 1984):
C = morphological type of calculus
C1 = coraliform calculus without calyceal parts
C2 = coraliform calculus with calyceal parts
R = renal parenchyma state
R1 = thin parenchyma
R2 = normal parenchyma
R3 = “juicy”, edematous, turgescent kidney
B = pelvis appearance
B1 = large pelvis „complesant”
B2 = small pelvis (intrasinus)
B3 = „scar” pelvis (iterative surgery)
Urinary lithiasis classification
Topographical:
Parenchymal lithiasis
Calyceal lithiasis
Pyelocaliceal lithiasis
Ureteral lithiasis
Bladder lithiasis
Prostate lithiasis
Urethral lithiasis
Urinary lithiasis classification
Depending on the number and distribution of calculi:
Single
Multiple, which, in their turn, can be located
•Unilateral
•Bilateral
Depending on the presence or absence of relapses:
Non-relapsing
Relapsing
Multiple relapsing (malignant)
According to the criterion of complications:
Uncomplicated lithiasis
Complicated lithiasis (association lithiasis-urinary infection-
hypertension-renal failure)
Urinary lithiasis classification
Depending on evolution, it can be divided in 4 groups:
4. Nephromegaly – consecutive to
hydronephrosis or lithiasic
ureterohydronephrosis, can be unilateral or
bilateral. Usually, it also associates other signs or
symptoms such as pain, pyuria, signs of cute
pyelonephritis or even signs of renal failure.
Clinical diagnosis of urinary lithiasis
5. Renal failure:
Acute – is manifested as anuria, when lithiasis obstruction
occurs on one kidney congenital, surgical or functional. Less
often because of bilateral obstruction, by calculi.
Chronic – occurs slowly, usually in patients with old history
of lithiasis, with bilateral manifestations, which the combination
obstruction+urinary infection caused extensive nephron
destructions, the functional deficit being compensated primarily
by polyuria, and then to establish the complex clinical picture
of uremia.
Clinical forms of urinary lithiasis:
Subclinical form – characterizes small calculi, fixed or the coraliform ones
and develop asymptomatically, the diagnosis being established, during a
radiological or ultrasound exploration for another disease.
Painful form – the dominant symptom is the pain that varies from
nephralgia to renal colic.
Hematuria form – hematuria can be solitary, raising problems of differential
diagnosis with tumor pathology.
Nephromegaly form – caused by stasis and hypertension superjacent to
calculus.
Febrile form – is determined by overlap of infection and requires
differential diagnosis between inobstructive acute pyelonephritis and lithiasis
one.
Hypertensive form – is characterized by presence of renal hypertension.
Digestive form – is characterized through digestive phenomena prevalent
reflexes and consist of abdominal and lumbar pains, nausea, vomiting,
flatulence.
Form with chronic renal failure
Laboratory diagnosis of renal lithiasis
Laboratory examinations – in order to specify the bioumoral status of the patient,
require, in addition to usual tests (complete blood count, urea and serum
creatinine, glycemia, liver and coagulation tests) and monitoring of diuresis, to
determine the urinary density and pH, urinalysis, leukocytes and erythrocytes
count in ruine (Addis, Neciporenko, Hamburger and Stansfeld Webb tests).
Specific laboratory examinations consist in:
Serum dosing of: calcemia; phosphatemia; uric acid; bicarbonates.
Urinary dosing of: calciuria; phosphaturia; uricosuria; cystinuria;
creatinuria; urea; oxaluria; magnesiuria; citraturia.
Urinalysis: pH; urinary density; presence of erythrocytes, leukocytes,
crystals in urine.
Urine culture with antibiogram.
Diagnosis of renal lithiasis
Imaging is represented by:
Ultrasound
Simple reno-bladder X-ray and intravenous urography
Computed tomography and magnetic resonance imaging
Retrograde or anterograde ureteropyelography
Angiography
Renal scintigram with isotopic nephrogram
Imaging
Ultrasound – is a noninvasive method, that can
allow revealing the calculus, and its echo on the
pyelocaliceal system and kidney (by assessing the
degree of hydronephrosis and renal parenchymal
index). Doppler ultrasound may reveal increased
resistivity index in obstructed kidney, as well as
asymmetry or absence of uretero-bladder jets.
Imaging
Simple reno-bladder X-ray (SRBR) and intravenous
urography (IVU) – SRBR is the first radiological exploration
within the initial investigation protocol. It can reveal the
presence of radiopaque images of various shapes and sizes,
located on the projection area of the kidney and ureter track.
IVU can reveal both the radiopaque calculi and the radiolucent
ones (as defective image surrounded all around by contrast
agent).
It specifies the location of lithiasis, its size, effect on urinary
superjacent tracts, the state of renal parenchyma and renal
function.
Imaging
Computed tomography (CT) and magnetic resonance imaging
(MRI) – CT allows a good retroperitoneal exploration, provides data on
“blind”, retroperitoneal areas. CT highlights the non-functional kidney at
IVU. Even if performed without contrast agents, CT manages to
decipher renal problems of uremics or the allergic ones to contrast
agents. Spiral CT examination with three-dimensional reconstruction is a
relatively new method, with demonstrated utility especially in coraliform
lithiasis.
MRI proved to be useful in detecting urinary tract obstruction and allows
assessing of hydronephrosis. This method can be used in patients with
impaired renal function or allergy to contrast agent, for whom the
ultrasound is contraindicated. Unlike CT, MRI does not allow
visualization of the majority of ureteral calculi, making rare use of this
method in assessing the lithiasis patients.
Imaging
Retrograde or anterograde
ureteropyelography– is used increasingly rare,
being useful for radiolucent calculi, which location
is difficult to determine by other means, in case of
non-function kidney, in patients with renal failure
or allergy to contrast agent.
Imaging
Angiography – It is rarely used for lithiasis patients. This
investigation can be useful when a vascular malformation is
suspected as a causal factor of stasis or in diagnosis of lithiasis
associated with reno-vascular hypertension.
Relative:
• Untreated urinary tract infections
• Tuberculosis
• Pregnancy
Ureteroscopy complications
• Ureter perforation
• Ureteral avulsion
• Intraoperative defects of endoscopic instrumentation
• Ureteric mucosal injury
• SCB perforation
• Late complications: ureteric stenosis <1%
ureteral-bladder reflux <1%
Percutaneous nephrolithotomy
PNL is endoscopic surgical procedure in which
the calculus from kidney is extracted after
percutaneous puncture of the renal hollow
system and dilation of the access channel thus
created. When the calculus size or its shape does
not allow direct extraction through the created
channel, various procedures of calculus
destruction are applied.
PNL stages
• SCB opacity
• SCB puncture
• Dilation and creation of percutaneous access
channel in the intrarenal urine tract
• Nephroscopy
• Extraction of calculi or lithotripsy "in situ" of
calculi
• Kidney drainage (nephrostomy)
PNL complications
Early complications Late complications
Fever 32% Arteriovenous fistulas <1%
SCB perforation 5-7% HTA <1%
Nephrostomy dislocation 4-16% Lithiasis relapse 3%
Hemorrhaging
Septicemia 3%
Hydrothorax 2%
Colon perforation 1%
Deterioration of renal function 3%
Open surgery
Being invasive they are being applied less Specific indications:
– Lack of technical possibilities of applying mini-invasive methods
– Failure of mini-invasive methods
– Require open surgery in order to correct associated pathologies (plastic
JPU, ureter)
– Afunctional kidney (nephrectomy)
– Large or complex shaped calculi
– Obesity II-III degree
– Skeleton deformations
– Coraliform urolithiasis with associated infundibular stenosis or calculus
with caliceal ramifications
Open surgery
• Pyelolithotomy
• Pyelonephrolithotomy
• Nephrolithotomy
• Ureterolithotomy
• Nephrectomy
Laparoscopic surgery
• Laparoscopic pyelolithotomy
• Laparoscopic ureterolithotomy
• Robotic assisted laparoscopy ”Da Vinci”