Kidney, ureteral and bladder stones

What is it?

Calculosis (or lithiasis from the Greek “lithos” – stone) is one of the pathological conditions that most frequently affects the urinary tract. It involves the formation of aggregates of minerals and organic substances that, once deposited, appear as real pebbles inside the excretory cavities of the kidney. The main problem caused by kidney stones is that they can obstruct the passage of urine to the bladder. Such obstruction may affect almost the entire length of the urinary tract. We speak of renal stones when stones are identified in the kidneys, ureteral stones when stones from the kidney enter the ureter and bladder stones when stones are found in the bladder. Stones found in the bladder may have descended from the kidney or may have formed directly in the bladder, due to urinary stasis that occurs in some patients with benign prostatic hypertrophy. Although in the past bladder stones were the most frequent of the three types, today they are by far the least frequent, having given way to renal and ureteral lithiasis. Urinary stones is a very frequent event (and globally increasing) in the general population: it is estimated that it can affect up to 10-15% of adults taking into account differences in age, gender, ethnicity, latitude; it is known that men (peak incidence 30-69 years) are affected about three times more than women (peak incidence 50-79 years), although this difference is increasingly reducing. Other risk factors include Caucasian race, living in hot and arid regions, sedentary work, exposure to high temperatures, obesity, familial anamnesis, presence of kidney malformations, and poor water intake. The formation of kidney stones, therefore, does not occur in all subjects, but only in some people and at certain times, which is connected with the alteration of the balance in the amount of substances eliminated through the kidney in the urine and urinary volume inadequate to prevent these substances from sedimentation and aggregation forming stones. Queste alterazioni possono essere momentanee (circoscritte a particolari momenti della vita, influenzate dai fattori sopra elencati) o continue (alterazioni metaboliche). There are different types of calculi classified according to their chemical composition: the most frequent are calculi containing calcium (about 75% of the total), in particular those containing calcium oxalate (about 60% of the total). Among calcium-free stones the most frequent are those consisting of uric acid. Most stones form due to a combination of genetic and environmental factors.

Which are the symptoms?

The main symptom of calculosis is colic, a sharp and very intense pain associated with nausea, vomiting and general malaise. This pain has different characteristics depending on the localization of the stone: at renal level (renal colic) there will be a dull and constant pain in the lumbar region that radiates to the side and anteriorly; at ureteral level (ureteral colic) the pain will often be intermittent and variable depending on the location along the course of the ureter, starting from the side until the groin, the testicle in men and the labia majora in women and the inner thigh. With regard to bladder stones, blood in the urine, difficulty and pain when urinating, widespread pain in the lower abdomen, increased number of nocturnal trips to the bathroom to urinate are the most common symptoms.

  • renal colic   
  • ureteral colic   
  • presence of blood in the urine   
  • pain or difficulty in passing urine   
  • widespread pain in the lower abdomen   
  • increased nocturnal urination    

How is it diagnosed?

Urological examination: during the examination, personal and family clinical information is collected. X-ray of the abdomen: highlights the radiopaque stones, so defined because they do not allow themselves to be crossed by x-rays. Ultrasonography of the urinary apparatus: it shows the state of dilatation of the renoureteral cavities and also radiolucent calculi, so defined because they allow themselves to be crossed by X-rays. CT scan of the abdomen: In order to have a precise indication of the presence of stones, their location, size and consequences caused to the excretory tract, it is necessary to perform a CT scan of the abdomen or an X-ray investigation with or without contrast medium, depending on the case. Hematochemical and urine tests: detect metabolic or functional alterations of the excretory system and possible traces of blood in the urine or crystal aggregates.

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How is it treated?

RENAL STONES. Extracorporeal shock wave lithotripsy (ESWL): stone fragmentation from outside with shock waves. This treatment is applicable in the presence of kidney stones that are not particularly hard, less than 2 cm in size and in normal weight patients. Percutaneous nephrolithotomy (PNL): a minimally invasive technique that involves accessing the renal cavities via percutaneous access and performing lithotripsy with ballistic and/or ultrasonic energy. This technique is used for large calculosis (> 2cm). Endoscopic lithotripsy with retrograde access (ureterorenoscopy or URS): minimally invasive technique that consists of going up inside the kidney by retracing the urinary system (urethra, bladder and ureter) to reach the stones and their fragmenting with laser energy.

URETERAL STONES. Extracorporeal shock wave lithotripsy (ESWL): fragmentation of the stone from the outside with shock waves. It applies only in selected cases (stones < 1cm and well visible at ultrasound/fluoroscopic targeting in normal weight patients). Endoscopic lithotripsy with retrograde access (ureterorenoscopy or URS): passing through the urethra and bladder (retrograde access) with endoscopic instruments, it goes back inside the ureter where the stones are fragmented with laser energy.

BLADDER STONES. Endoscopic lithotripsy by transurethral route: passing through the urethra, the bladder is reached, where the stones are fragmented with laser energy.

POSSIBLE COMPLICATIONS. Extracorporeal shock wave lithotripsy (ESWL) and endoscopic lithotripsy (URS) are less invasive treatments than percutaneous nephrolithotomy, which exposes you to higher risk of bleeding. In extracorporeal shock wave lithotripsy, the presence of blood in the urine after treatment is frequently observed, generally of low entity, and renal hematomas or kidney ruptures may occur, although in very low percentages. In endoscopic lithotripsy with retrograde access, ureteral lesions may occur such that corrective surgery is exceptionally required, or ureteral strictures after some time.

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