- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
Chapter 8
Stone disease
Kidney stones: epidemiology 356
Kidney stones: types and predisposing factors 358 Kidney stones: mechanisms of formation 360 Factors predisposing to specific stone types 362 Evaluation of the stone former 366
Kidney stones: presentation and diagnosis 368 Kidney stone treatment options: watchful waiting 370
Stone fragmentation techniques: extracorporeal lithotripsy (ESWL) 372
Intracorporeal techniques of stone fragmentation (fragmentation within the body) 374
Kidney stone treatment: flexible ureteroscopy and laser treatment 378
Kidney stone treatment: percutaneous nephrolithotomy (PCNL) 380
Kidney stones: open stone surgery 383
Kidney stones: medical therapy (dissolution therapy) 384 Ureteric stones: presentation 386
Ureteric stones: diagnostic radiological imaging 388 Ureteric stones: acute management 390
Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone 392
Ureteric stone treatment 394
Treatment options for ureteric stones 396 Prevention of calcium oxalate stone formation 398 Bladder stones 400
Management of ureteric stones in pregnancy 402
356 CHAPTER 8 Stone disease
Kidney stones: epidemiology
Approximately 10% of Caucasian men will develop a kidney stone by the age of 70. Within 1 year of a calcium oxalate stone, 10% of men will form another calcium oxalate stone, and 50% will have formed another stone within 10 years.
The prevalence of renal tract stone disease is determined by factors intrinsic to the individual and by extrinsic (environmental) factors. A combination of factors often contributes to the risk of stone formation.
Intrinsic factors
Age
Peak incidence of stones occurs between the ages of 20 and 50 years.
Sex
Males are affected 3 times as frequently as females. Testosterone may cause increased oxalate production in the liver (predisposing to calcium oxalate stones) and women have higher urinary citrate concentrations (citrate inhibits calcium oxalate stone formation).
Genetic
Kidney stones are relatively uncommon in Native Americans, Black Africans, and U.S. Blacks, and more common in Caucasians and Asians. About 25% of patients with kidney stones report a family history of stone disease (the relative risk of stone formation remaining high after adjusting for dietary calcium intake).
Familial renal tubular acidosis (predisposing to calcium phosphate stones) and cystinuria (predisposing to cystine stones) are inherited.1
Extrinsic (environmental) factors
Geographical location, climate, and season
The relationship between these factors and stone risk is complex. While renal stone disease is more common in hot climates, some endogenous populations of hot climates have a low incidence of stones (e.g., Black Africans, Aborigines), and many temperate areas have a high incidence of stones (e.g., Northern Europe and Scandinavia). This may relate to Western lifestyle—excess food, inadequate fluid intake, limited exercise— combined with a genetic predisposition to stone formation.
Ureteric stones become more prevalent during the summer
The highest incidence occurs a month or so after peak summertime temperatures, presumably because of higher urinary concentration in the summer (encourages crystallization). Concentrated urine has a lower pH, encouraging cystine and uric acid stone formation.
Exposure to sunlight may also increase endogenous vitamin D production, leading to hypercalciuria.
1 Curhan GC, Willett WC, Rimm EB, Stampfer MJ (1997). Family history and risk of kidney stones.
J Am Soc Nephrol, 8:1568–1573.
KIDNEY STONES: EPIDEMIOLOGY 357
Water intake
Low fluid intake (<1200 mL/day) predisposes to stone formation.2 Increasing water hardness (high calcium content) may reduce risk of stone formation, by decreasing urinary oxalate.
Diet
High animal protein intake increases risk of stone disease (high urinary oxalate, low pH, low urinary citrate).3,4 High salt intake causes hypercalciuria. Contrary to conventional teaching, low-calcium diets predispose to calcium stone disease, and high-calcium intake is protective.5
Occupation
Sedentary occupations predispose to stones more than manual work.
2 Borghi L, et al. (1996) Urinary volume, water and recurrences in idiopathic calcium nephrolithiasis: a 5-year randomized prospective study. J Urol 155:839–843.
3 Curhan GC, et al. (1997) Comparison of dietary calcium with supplemental calcium and other nutrients as factors affecting the risk for kidney stones in women. Ann Intern Med 126:497–504.
4 Borghi L, et al. (2002) Comparison of 2 diets for the prevention of recurrent stones in idiopathic hypercalciuria. N Engl J Med 346:77–84.
5 Curhan GC, et al. (1993) A prospective study of dietary calcium and other nutrients and the risk of symptomatic kidney stones. N Engl J Med 328:833–838.
358 CHAPTER 8 Stone disease
Kidney stones: types and predisposing factors
Stones may be classified according to composition (Table 8.1), X-ray appearance, or size and shape.
Other rare stone types (all radiolucent) include indinavir (a protease inhibitor for treatment of HIV), triamterene (a relatively insoluble potas- sium-sparing diuretic, most of which is excreted in urine), and xanthine.
Radiodensity on X-ray
Three broad categories of stones are described, based on their X-ray appearance. This gives some indication of the likely stone composition and helps to some extent to determine treatment options.
However, in only 40% of cases is stone composition correctly identified from visual estimation of radiodensity on plain X-ray.1
Radio-opaque
Opacity implies presence of substantial amounts of calcium within the stone. Calcium phosphate stones are the most radiodense stones, almost as dense as bone. Calcium oxalate stones are slightly less radiodense.
Relatively radiolucent
Cystine stones are relatively radiodense because they contain sulfur (Fig. 8.1). Magnesium ammonium phosphate (struvite) stones are less radiodense than calcium-containing stones.
Completely radiolucent
Uric acid, triamterene, xanthine, indinavir stones are in this category (cannot be seen even on CTU).
Table 8.1 Composition of kidney stones
Stone composition |
% of all renal calculi* |
Calcium oxalate |
85% |
Uric acid† |
5–10% |
Calcium phosphate + calcium oxalate |
10% |
Pure calcium phosphate |
Rare |
Struvite (infection stones) |
2–20% |
Cystine |
1% |
* The precise distribution of stone types will vary depending on the characteristics of the study population (geographical location, racial distribution, etc.). Hence, the quoted figures do not equate to 100.
†~80% of uric acid stones are pure uric acid; 20% contain some calcium oxalate.
1 Ramakumar S, Patterson DE, LeRoy AJ, et al. (1999) Prediction of stone composition from plain radiographs: a prospective study. J Endosc Urol 13:397–401.
KIDNEY STONES: TYPES AND PREDISPOSING FACTORS 359
Size and shape
Stones can be characterized by their size, in centimeters. Stones that grow to occupy the renal collecting system (the pelvis and one or more renal calyx) are known as staghorn calculi, since they resemble the horns of a stag (Fig. 8.2). They are most commonly composed of struvite—magne- sium ammonium phosphate (being caused by infection and forming under the alkaline conditions induced by urea-splitting bacteria), but may consist of uric acid, cystine, or calcium oxalate monohydrate.
Figure 8.1 A left cystine stone, barely visible just below the midpoint of the 12th rib.
Figure 8.2 A large, right staghorn calculus.