NEPHROLITHIASIS :

Surgical treatment and metabolic evaluation

Dr. Syah Mirsya Warli, SpU Dr. Bungaran Sihombing, SpU
Urology Division, Surgery Department Medical Faculty, University of Sumatera Utara

PRESENTATION

Renal colic - classically : flank pain, often acute in onset, radiating to the ipsilateral abdomen - distal ureteral stones ipsilateral groin, testicular (can mimic torsion or epididimytis), vulvar pain - waxes & wanes - frequently move about to find a more comfortable position

RENAL COLIC

Sudden onset, no relief with change of position Nause & vomiting Diagnosis studies : - urinalysis - non-contrast CT scan - plain radiograph - white count and serum creatinin - urine culture - IVP

Nausea & vomiting Irritative voiding symptom Hematuria (gross or microscopic) Urinary infection Fever, esp if infection present Occasionally asymptomatic, with stones detected incidentally

PAST MEDICAL HISTORY

fluid intake Urinary tract infection High-protein diet (associated with acidosis, hypocitraturia, hypercalciuria, hyperuricosuria, hyperoxalouria) Intestine Bowel Disease, small bowel resection, jejunoileal bypass (hyperoxaluria & Ca oxalate stones) Primary hyperparathyroidism (hypercalciuria & Ca oxalate stone) Gout (uric acid stone) Total colectomy (uric acid stone)

Renal Tubular Acidosis (Ca phosphate stones) Medication : - steroids (hypercalciuria) - loop diuretics (hypercalciuria) - colchicine (hyperuricosuria) - vitamin D - antacids - triamterene - indinavir

Associated Genito Urinary diseases: - UPJ obstruction - bladder reconstruction - BPH - medullary sponge kidney Family history of stones Social history : - immobility and sedentary lifestyle risk - wine / beer risk

EVALUATION IN THE ACUTE SETTING

PHYSICAL EXAM - evaluate for fever concomitant infection may be associated with tachycardia and/or hypertension - abdominal exam to evaluate for flank tenderness/peritonitis

URINALYSIS AND URINE CULTURE

RBC usually present, WBC may be present pH : < 5.5 + radioluscent stone uric acid stone
> 5.5 + metabolic acidosis, hypokalemia & hyper chloremia RTA > 6.0 struvit

Crystals :
Ca oxalate dumbbell/hourglass/bipyramidal Ca phosphate needle-shaped/amorphous uric acid amprphous/rosettes struvite coffin lid cystine benzene ring/hexagonal

SERUM STUDIES

Complete blood count Electrolytes Calcium Phosphate Uric acid

IMAGING

KUB - 5 typical location of stone impaction : calyx ureteropelvic junction (UPJ) pelvic brim (iliacs) posterior pelvis (broad ligament, females) ureterovesical junction (UPJ)

KUB

Intravenous pyelogram (IVP) - nowadays, rarely used in the acute setting Ultrasound - pregnancy & pediatrics : avoids radiation - poor visualization of small renal & ureteral stones

IVP

USG

Non-contrast computed tomography - 97% sensitive & 97% specific for stone - 4 signs of obstruction : hydroureter hydronephrosis perinephric stranding nephromegaly

ACUTE MANAGEMENT

Pain control : - narcotics - NSAIDS IV fluids AB if urinary infection (+) Strain urine Recommended indication for admission :
uncontrolled pain unremitting nausea/vomiting obstructed, infected renal unit obstructed, solitary renal unit bilateral obstruction anuria

Recommended indication for watchful waiting - no evidence of infection - pain well-controlled with oral medication - stone < 5 mm - no obstruction Spontaneous stone passage rates based on location : - proximal : 20% - distal : 70%

Spontaneous passage rates within 1 year : < 4 mm 90% 4 6 mm 60% > 6 mm 20%

Obstruksi ureter akut prostaglandin

Vaso dilatasi ginjal

Suspresi hormon anti diuretik

diuresis

Peningkatan tekanan pelvis renalis

Nyeri meningkat

Obstruksi ureter akut

Peningkatan tekanan pelvis renalis

Dilatasi pelvis renalis

Edema perirenal dan periureter

Kerusakan ginjal : terjadi oleh karena iskhemia infark / nekrosis pada duktus koligentes dan tubulus proksimalis

MEDICAL OPTIONS DURING EXPECTANT MANAGEMENT

Pain control AB prophylaxis Alpha blockers Ca channel blockers steroids

SURGERY

ESWL - imaging : fluoroscopy - anesthesia : sedation or general - potential long-term renal effect :
renal injury/scar, hypertension

- complications :
hematoma (<1%) obstruction UTI/sepsis injury to organ calcified aneurysm bleeding diathesis

- contraindications :
pregnancy morbid obesity

Ureteroscopy Percutaneous nephrolithotripsy

ESWL : Extra Corporeal Shock Wave Lithotripsy

Sebelum ESWL

Foto setelah ESWL

Foto setelah ESWL

STONE FREE RATES

proximal ureter
<1.0 cm ESWL Ureteroscopy PCNL

distal ureter 85% 89% 74% 73% -

84% 56% 76%

72% 44% 74%

1.0 cm ESWL Ureteroscopy PCNL

STONE FRAGMENTATION TECHNOLOGIES

Electrohydraulic lithotripsy Holmium : YAG laser Ballistic lithotripsy (pneumatic) Ultrasonic lithotripsy

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