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7/27/2019 Kuliah Batu

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Urinary Stone Disease

Dr.Moh.Galuh Richata, SpU


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Prologue

Urinary Stone Disease (urinary calculi,

urolithiasis) is the disease with

development of stones in the urinary tract.

Its the 3rd most common disease in the

urinary tract, after infections and prostate

disease.

Its have plagued humans since the

earliest records of civilization.


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Nomenclature

Urinary Tract Stones Urolithiasis

Kidney Stones Nephrolithiasis

Pyelum: Pyelolithiasis Calix: Calix stones

Pyelum + Calix : Staghorn stones

Ureter Stones

Ureterolithiasis Bladder Stones Vesicolithiasis

Urethra Urethrolithiasis


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Etiology

Theory of Stone Formation is still incomplete

and debatable.

Polycrystalline aggregates composed of varying

amounts of crystalloid and organic matrix. Stone formation requires supersaturated urine.

Supersaturat iondepend on: urinary pH, ionic

strength, solute concentration, andcomplexation.


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Urinary Ions

1. Calcium (major ion in urinary crystals)2. Oxalate (normal waste of metabolism)

3. Phosphate (important buffer, complexeswith calcium)

4. Uric Acid (product of purine metabolism)

5. Sodium (regulates crystallization ofcalcium salts)

6. Citrate (affect the development ofcalcium stones, but can inhibit stoneinformation)


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7. Magnesium (component of struvitestones, can inhibit stone information)

8. Sulfates (may help prevent stone

formation)9. Other Urinary Stone Inhibitors:

glycosaminoglicans, pyrophosphates,

uropontin.


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Stone Varieties

A. Calcium Calculi:1. Absorptive Hypercalciuric Nephrolithiasis

2. Resorptive Hypercalciuric Nephrolithiasis

3. Renal induced Hypercalciuric Nephrolithiasis4. Hyperuricosuric Calcium Nephrolithiasis

5. Hyperoxaluric Calcium Nephrolithiasis

6. Hypocitraturic Calcium Nephrolithiasis

B


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B. Non Calcium Calculi:1. Struvite (MAP = magnesium ammonium

phosphate, frequently as staghorn stones)

2. Uric Acid

3. Cystine

4. Xanthine (deficiancy of xanthine oxidase)

5. Indinavir

6. Others


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Sign & Symptoms

of Upper Urinary Tract Stones

A. Pain: 2 types of pain origin from kidney:

Renal Colic (caused by stretching of the

collecting system or ureter)

Noncolicky Renal Pain (caused by the

distention of the renal capsule)


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Renal Colic

Can come in waves, but also may berelatively constant.

The onset can be very sudden and severe.

Patients frequently move constantly tryingto relieve the pain.

The severity and location of the pain can

vary, depends on: stone size, stonelocation, degree of obstruction, acuity of

obstruction, and variation of anatomy.


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Sign & Symptoms

B. Hematuria:Can be gross (macroscopic) or microscopic

hematuria.

Most patients will have at least microscopichematuria.


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Sign & Symptoms

C. InfectionAll stones may be associated with urinary tract infection,secondary to obstruction and stasis proximal to the stonewhich has caused the obstruction.

Any urinary infection can lead to urosepsis. Sign of

sepsis: fever, tachycardia, hypotension, tachypnea.

D. Nausea and Vomitting

Frequently associated with upper urinary obstruction.


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Diagnosis

A. History Taking

Pain (onset, character, radiation,

activities), Nausea/vomit, gross

hematuria, fever, cloudy urine, passing

stone/sand. Voiding disorders.

B. Physical Examination

General Condition (in pain,


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Diagnosis

B. Physical Examination

General Condition (gestures in pain, body

temperature, heartbeat, etc)

Flank region (ad regio lumbalis):

inspection, palpation, percussion

(costovertebral angle).


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Diagnosis

Laboratory Examination

Blood: Hb, Leukocyte, Ureum, Creatinine,

Uric Acid

Urine: pH, Erythrocyte, Leukocyte,

Sediments (crystal, bacteria, epithelium).

Urine Culture (type, colony counts, resistant

test)


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Diagnosis

Imaging (radiologic investigations)- Ultrasound

- Plain Abdomen (KUB/BNO)

- Intravenous Pyelography/Urography(IVP/IVU)

- Retrograde Pyelography

- Computed Tomography Scan- Magnetic Resonance Imaging


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Intervention

1. Conservative Observation

Ureter stones can spontaneously pass but

depends on: stone size, shape, location,

ureteral edema (duration of stay).Stone 4-5 mm have 40-50% chance of pass

Stone > 6 mm have 5 %.

Sometimes need specific drug to help thestone to pass.


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Intervention

2. Dissolution Agents

Very depends on stone surface area,

stone type, volume of irrigant, mode of

delivery, kidney function.

Only effective on small stones (


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Intervention

3. Open Surgery (Nephrolithotomy, etc)

4. Endoscopic Surgery:

URS (Ureterorenoscopy)

PNL (Percutaneous Nephro-Litholapaxy).

5. ESWL (Extracorporeal Shock Wave

Lithotripsy)


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Lower Urinary Tract Stones

Bladder Stones

> The surgery of bladder stones is one ofthe three oldest surgical procedure known

in human history.> Etiology of bladder stones:

Underlying bladder outlet disorders

Foreign bodies (IUD, worms, etc) Systemic/Metabolic disorders (children

with malnutrition)


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Diagnosis

of Bladder Stones

History: Irritative voiding symptoms,

intermittent urinary stream, urinary tract

infections, pelvic pain.

Physical Examination:

- General condition

- Lower Abdominal Region (Suprapubic)- Digital Rectal Examination


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Diagnosis

of Bladder Stones

Laboratory: urine

Imaging: Ultrasound, KUB/BNO


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Intervention

- Open Surgery (Vesicolithotomy, Sectio

Alta)

- Endoscopic Surgery: Cystoscopy &

Lithotripsy

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