Urolithiasis

Urology Division, Surgery Department

Faculty of Medicine,
University Sumatera Utara
Learning Objectives
• Able to explain about the relationship between stones and
metabolism
• Able to explain the etiology and theory of the stone formation
• Able to diagnose clinically based on symptoms, physical examination,
lab, and radiology
• Able to explain the management of urinary tract stones
• Know when to refer to specialists
Introduction

Pathogenesis

Manifestation

Diagnosis

Management
Standar Kompetensi Dokter Indonesia (SKDI)
No Topik Tingkat Tingkat Kemampuan
Kompetensi
1 Urolithiasis • Mendiagnosis,
• Melakukan
3A
Penatalaksanaan Awal,
• Merujuk (Gawat Darurat)

Lulusan dokter mampu :

• Membuat diagnosis klinik
• Memberikan terapi pendahuluan pada keadaan yang gawat darurat demi menyelamatkan nyawa
atau mencegah keparahan dan/atau kecacatan pada pasien
• Menentukan rujukan yang paling tepat bagi penanganan pasien selanjutnya.
• Menindaklanjuti sesudah kembali dari rujukan.
References
Introduction
Urinary stones define as the formation of stones in the urinary tract (kidney,
ureters, bladder, and urethra)

Epidemiology
• Male: Female 3: 1
• Most aged 40-50 years
• High Body Mass Index
• Hot Climate area
• Sedentary Lifestyle

Rasyid N, Duarsa GWK, Atmoko W. Panduan Penatalaksanaan Batu Saluran Kemih 2018. IAUI. Jakarta, 2018
Pearle MS, Antonelli JA, Lotan Y. Urinary lihiasis: etilogy, epidemiology and pathogenenis. Campbell-Walsh Urology. 11 th edition. 2016
Epidemiology

Jepang (2005) 🡪 114.3 per 100,000

Taiwan (2002) 🡪 9.6 per 100,000

Thailand (1997) 🡪 16.9 per 100,000

Indonesia
±170.000/ year

Stone belt (red) extends all the way around the world and is 1.Lieske JC, Peña de la Vega LS, [et.al]. Kidney Int. 2006
2.Trinchieri A. Clin Cases Miner Bone Metab. 2008
characterized by urinary stone prevalence of 10 to 15%. 3.Pearle MS & Lotan Y; Campbell Walsh Urology 2007
Stone Formation Pathogenesis

• Supersaturation
• Nucleation
• Absence of inhibitors
• Epitaxy theory
Supersaturation
Nucleation

• Nidus/nucleus 🡪 precipitation core

• Conditions that cause nidus:
✔ Mucosal ulceration
✔ Blood clots
✔ Epithelial cells or pus
✔ Bacteria
✔ Necrotic tissue
✔ Foreign object
Absence of inhibitors

• Loss or reduce inhibitors capabilities 🡪 supersaturation processes

• Stone formers mostly lack these inhibitors:
• Magnesium
• Citrate
• Pyrophosphate
• Amino acid (alanine)
Epitaxy Theory

• Precipitation of crystals on top of other crystals

• Example: uric acid stone enveloped in calcium oxalate

Risk Factors

• Age, Race and Sex

• Climate and Seasons
• Dietary Habits
• Comorbidity

Epidemiology and risk factors in urolithiasis.

R. Bartoletti, T. Cai, N. Mondaini, F. Melone, F. Travaglini, M. Carini, M. Rizzo
Urol Int. 2007; 79 (Suppl 1): 3–7. doi: 10.1159/000104434
Stone types
Characteristic based on causes
Non-infection stones
🡪 Calcium oxalate, Calcium phosphate,
Uric acid
Infection stones
🡪 Magnesium ammonium phosphate,
Carbonate apatite, Ammonium urate
Genetic causes
🡪 Cystine, Xanthine,
2,8-Dihydroxyadenine
Drug stones

1. EAU 2019. Guidelines on Urolthiasis

Clinical Manifestation

• Symptoms
• Asymptomatic
• Mild back pain to colic pain
• Nausea + vomit
• Hematuria
• Dysuria
• Urinary retention

• History of past illness:

• Obesity
• Primary hyperparathyroid
• Gastrointestinal malabsorption
Rasyid N, Duarsa GWK, Atmoko W. Panduan Penatalaksanaan Batu Saluran Kemih 2018. IAUI. Jakarta, 2018
• Intestinal / pancreatic disease
Symptoms and signs of upper tract calculi

Loin pain Loin tenderness

radiating
to groin

Strangury/
dysuria Haematuria-macro or micro
 Differential diagnosis
• Nefrolitiasis
• Ureterolitiasis
• Vesikolitiasis
• Obstruksi Traktus Urinarius
• Infeksi Traktus Urinarius
INITIAL EVALUATION : INVESTIGATION
Imaging Serum Stone Analysis

• Quantify stone burden • Electrolyte (Na, K, Cl, bicarbonate) • Attempt to send stone for analysis
• Findings that may be indicative of an • Calcium • Urine strainer
underlying metabolic disorder • Creatinine • Surgical removal
• Multiple calculi • Uric acid • Stone type impacts the importance
• Bilateral calculi • PTH of 24 hours urine collection
• Nephrocalcinosis • Hyperparathroidism suspected • Repeat stone analysis is important
• Urine for recurrent stones
• Urinalysis with microscopy
• pH
• Urine culture (infection suspected)
• Stone analysis
• Attempt to send stone for analysis
• Urine strainer
• Surgical removal
• Stone impacts the importance of
24 hours urine collection
• Repeat stone analysis is important
for recurrent stone

Dion M, et al. CUAJ 10 (11-12): 2347-58, 2016, Jung H, et al. World J Urol 35:1331-402017, Pearle M, et al. J Urol 192(2):316-24, 2014
Extensive Metabolic Evaluation
• Indications:
• Interested first time stone formers
• Children
• Family history of stones Additional metabolic testing
• Multiple, bilateral or recurrent stones aimed at identifying metabolic
• Prior percutaneous nephrolitotomy and dietary factors to help direct
• Non-calcium stones therapy
• Pure calcium phosphate stones
• Complicated stone episode
• Acute kidney injury, sepsis, hospitalization
• Reccurent urinary tract infection
• Solitary kidney
• Renal insufficiency
• Systemic disease
• Obesity, gout, osteoporosis, bowel disorders, hyperparathyroidism, distal RTA, DMII
• Occupation where public safety is at risk

Dion M, et al. CUAJ 10 (11-12): 2347-58, 2016, Pearle M, et al. J Urol 192(2):316-24, 2014
 IMAGING STUDY

Ultrasonography
• Primary imaging modality 🡪 An emergency measures
• Preferred method for pregnant woman
• There is no radiation risk, practical and affordable
• Operator-dependent

EAU 2019. Guidelines on Urolthiasis

USG
 IMAGING STUDY
BNO/KUB
• KUB can be used for evaluation
during follow-up
• KUB urography can differentiate
between radio-lucent and
radio-opaque stones

A.Heidenreich et al./EuropeanUrology 41(2012) 351±362

BNO descriptions
• Radioopaque lesions sized.... X ... mm as high as L ... on the
projection ...
EAU 2019. Guidelines on Urolthiasis
X-ray Stone Characteristic
Radio-opaque Poor radio-opaque Radioluscent
Calcium oxalate dihydrate Magnesium ammonium phosphate Uric acid

Calcium oxalate monohydrate Apatite Ammonium urate

Calsium phosphat Cystine Xanthine
2,8-dihydroxyadenine

Calcium Stone Cystine Stone Uric Acid Stone

IMAGING STUDY
Non-Contrast CT (NCCT)
• Gold standard
• Identify : stone diameter and density, stone structure and skin to stone distance
• Relatively high risk of radiation
• Advantages :
Disadvantage :
✔ High sensitivity & specificity
✔ Unavailable in remote area
✔ High diagnostic accuracy
✔ Limited urinary tract information
✔ Early detection of other abnormalities

1. EAU 2017. Guidelines on Urolthiasis

2. A.Heidenreich et al./EuropeanUrology 41(2002) 351±362
IMAGING STUDY

1. EAU 2019. Guidelines on Urolthiasis

Metabolic Investigation of Urinary Calculi
24 hour urine Volume
Calcium
Uric acid
Oxalate
Citrate

Spot urine pH

Blood tests Urea, electrolytes, creatinine

Calcium, phosphate, alkaline phosphatase
Uric acid, chloride, bicarbonate
 Emergency in Urinary Stone
• Urinary stone that accompanied by:
• Sepsis
• Anuria
• Hydronephrosis

• Decompression management:
• Ureteral stent
• Percutaneous nephrostomy

Rasyid N, Duarsa GWK, Atmoko W. Panduan Penatalaksanaan Batu Saluran Kemih 2018. IAUI. Jakarta, 2018
 Pharmacological Therapy
• Medical Expulsion Therapy (MET)
❑ α-blocker
❑ CCB (nifedipine)
❑ PDE5i (tadalafil)
• Recommendations :
• Distal ureteral stones; <4 mm
• Contraindicated if there are any evidence of infections, decreased renal
function, and recurrent pain or unmanageable by drug!

Urolithiasis Guidelines EAU 2019

 Indications for Active Removal of Kidney Stones

• Increased stone size •Stone size> 15 mm

• High risk stone formers •Stone size <15 mm if
• Obstruction caused by stones observation is not an option
• Stone associated with Urinary •Patient Preferences
tract infection Comorbidities
• Recurrent pain and hematuria •The patient's social condition

Rasyid N, Duarsa GWK, Atmoko W. Panduan Penatalaksanaan Batu Saluran Kemih 2018. IAUI. Jakarta, 2018
Renal stone
 Management of Kidney Stones

PN
L

RIR
S

ESW
L
Ureteric stone
 Ureter Stone Management Algorithm

Rasyid N, Duarsa GWK, Atmoko W. Panduan Penatalaksanaan Batu Saluran Kemih 2018. IAUI. Jakarta, 2018
Ureteroscopy
Bladder Stone
 Bladder Stone
Management
Algorithm

Rasyid N, Duarsa GWK, Atmoko W. Panduan Penatalaksanaan Batu Saluran Kemih 2018. IAUI. Jakarta, 2018
Bladder Stone - Lithalopaxy
General preventive measures

Fluid amount: 2.5-3.0 L/day

Circadian drinking
Fluid Intake Neutral pH beverages
Diuresis: 2.0-2.5 L/day
Specific weight of urine: < 1010
Balanced diet*
Rich in vegetables and fibre
Nutritional advice for
Normal calcium content: 1-1.2 g/day
a balanced diet Limited NaCl content: 4-5 g/day
Limited animal protein content: 0.8-1.0 g/kg/day
BMI: retain a normal BMI level
Lifestyle advice to normalise general
Adequate physical activity
risk factors Balancing of excessive fluid loss

1. EAU 2019. Guidelines on Urolthiasis

Thank You