URETERAL CALCULI

Khori Halimah
30101206653

Pembimbing :
dr. Ahmad Sulaiman Lubis, Sp.U
Surgical Anatomy
of Ureters
Anatomy

The ureters are bilateral tubular

structures responsible for
transporting urine from the
renal pelvis to the bladder
.They are generally 22 to 30
cm in length with a wall
composed of multiple layers.
 Anatomic Relationships

This crossover point is usually at

the bifurcation of the common iliac
into the internal and external iliac
arteries, thus making this a useful
landmark for pelvic procedures.
ureteropelvic junction, crossing of
the iliac vessels, and the
ureterovesical junction (Fig. 1–45).
 Pelvic Ureter
The ovarian vessels (infundibulopelvic ligament) cross the iliac vessels
anterior and lateral to the ureter, and dissection of the ovarian vessels at
the pelvic brim is a common cause of ureteral injury (see Fig. 2–13).
Pyeloureterography discloses a narrowing of the ureter at the iliac vessels,
and ureteral calculi frequently become lodged at this location.
 Histology

The walls of the calices, pelvis,

and ureters are composed of
transitional cell epithelium under
which lies loose connective and
elastic tissue (lamina propria).
External to these are a mixture
of helical and longitudinal
smooth muscle fibers. They are
not arranged in definite layers.
The outermost adventitial coat
is composed of fibrous
connective tissue.
 Ureteral Segmentation and
Nomenclature
Alternatively, the ureter can be
divided into upper, middle, and
lower segments (Fig. 1–46). The
upper ureter extends from the
renal pelvis to the upper border
of the sacrum. The middle ureter
comprises the segment from the
upper to the lower border of the
sacrum. The lower (distal or
pelvic) ureter extends from the
lower border of the sacrum to
the bladder.
 Ureteral Blood Supply and
Lymphatic Drainage
The ureter receives its blood
supply from multiple arterial
branches along its course
(Fig. 1–47). Of greatest
importance to the surgeon is
that arterial branches to the
abdominal ureter approach
from a medial direction,
whereas arterial branches to
the pelvic ureter approach
from a lateral direction.
 Ureteral Innervation
• The exact role of the ureteral autonomic
input is unclear. Normal ureteral peristalsis
does not require outside autonomic input
but, rather, originates and is propagated
from intrinsic smooth muscle pacemaker
sites located in the minor calyces of the
renal collecting system
Ureteral Calculi
 ETIOLOGY

INTRINSIC

IDIOPATIC Heriditer
Age
Gender

EXTRINSIC
Geography: stone belt
Climate / temperature
Water / mineral intake
Diet: purine, oxalate
Work
Microscopic examination of urine sediment.
(Redrawn after Todd-Sanford-Davidson.)
Scanning electron micrographs
of various urinary crystals
 CLINICAL MANIFESTATION
• Colic pain when the stone is down
Hematuri if the stone is down

• Over pain: in the right lower abdomen,

inguinal and inner thighs

• Obstruction: continuous pain and infection

/ fever / urosepsis
Colic
# attacks of pain
# nauseous vomit
# nervous
Pain over to the inguial region
Flatulence (paralytic ileus)
Hematuria
 Pain Perception and Somatic
Referral
Renal pain fibers are
stimulated by tension
(distention) in the renal
capsule, renal collecting
system, or ureter. Direct
mucosal irritation in the upper
urinary tract may also stimulate
nociceptors. Signals travel with
the sympathetic nerves and
result in a visceral-type pain
referred to the sympathetic
distribution of the kidney
• and ureter (eighth thoracic
through second lumbar).
• Referred pain originates in a diseased organ but is felt at
some distance from that organ. The ureteral colic (Figure
3–1) caused by a stone in the upper ureter may be
associated with severe pain in the ipsilateral testicle; this
is explained by the common innervation of these 2
structures (T11–12). A stone in the lower ureter may
cause pain referred to the scrotal wall; in this instance,
the testis itself is not hyperesthetic.
 Additional Examination

• Urinalysis
• Physiological examination of the kidneys
• Abdominal radiograph / BNO
• PIV
• Ultrasound
DIFFERENTIAL DIAGNOSIS
• Urinary stones can mimic other retroperitoneal and
peritoneal pathologic states. A full differential diagnosis
of the acute abdomen should be made, including acute
appendicitis, ectopic and unrecognized pregnancies,
ovarian pathologic conditions including twisted ovarian
cysts, diverticular disease, bowel obstruction, biliary
stones with and without obstruction, peptic ulcer disease,
acute renal artery embolism, and abdominal aortic
aneurysm, to mention a few. Peritoneal signs should be
sought during physical examination.
 MANAGEMENT
Conservative management for a patient with a ureteral stone smaller than 5
mm is appropriate because there is a high likelihood of stone passage.
Ureteral stones larger than 5 mm are unlikely to pass spontaneously

Obstructed pyelonephritis due to a ureteral calculus is a not uncommon

and potentially life-threatening emergency that is best treated by urgent
decompression of the urinary trac.

SWL and ureteroscopy are highly effective for patients with ureteral
calculi.

Medical expulsive therapies with agents such as tamsulosin may promote

spontaneous stone passage.
 URETERORENOSCOPHY

Ureterorenoscopy is most frequently

performed for treatment of ureteral
stones, although >90% of ureteral stones
can be treated by ESWL either in situ or
after dislodgment of the ureteral stone
into the renal pelvis using a ureteral
catheter (push-back or flush-back
procedures). For the remaining
indications of ureteral stone treatment,
ureterorenoscopy is used for extraction
of stones, dislodgment of stones into the
renal pelvis for subsequent ESWL, and
intraureteral stone disintegration.
EXTRACORPOREAL SHOCK
WAVE LITHOTRIPSY
URETHEROLITOTOMY

Long-standing ureteral calculi—

those inaccessible with endoscopy
and those resistant to ESWL—can
be extracted with ureterolithotomy.
Again, a preoperative radiograph
documents stone location and
directs an appropriate incision..The
nerve hook is excellent to help
tease out the stone. A flank or
anterior abdominal muscle splitting
incision gives excellent exposure to
mid- and distal ureteral stones.
 Stone Factors

Location

Stone Burden

Stone Compositio

Duration of Stone Presence

Clinical Factors
•Pain
•Infection

•The Patient’s Expectations

•Solitary Kidney

• Aberrant Anatomy
 Technical Factors
ureteroscopy is the most cost-effective
treatment strategy for ureteral stones at all
locations, after observation fails.