Siswoyo

Dep. KMB-Kritis PSIK UNEJ

 Urolithiasis, kidney stones, renal stones, and renal calculi are
used interchangeably to refer to the accretion of hard, solid,
nonmetallic minerals in the urinary tract
Passage of a urinary stone is the most common cause of
acute ureteral obstruction
The pain may be some of the most severe pain that humans
experience
Complications of stone disease may result in severe infection;
renal failure; or, in rare cases, death.
Urinary stones have afflicted humankind since antiquity
The earliest recorded example being bladder and kidney
stones detected in Egyptian mummies dated to 4800 BC
The specialty of urologic surgery was recognized even by
Hippocrates, who wrote, in his famous oath for the physician,
"I will not cut, even for the stone, but leave such procedures
to the practitioners of the craft (obviously, Hippocrates was
not a urologist!!)
 Batu Ginjal berbentuk kecil, endapan keras
garam mineral dan asam pada permukaan
dalam ginjal
Nama lain:
renal lithiasis
Renal calculi
nefrolitiasis
Batu ginjal diklasifikasikan berdasarkan lokasi
pada sistem kemih dan komposisi batu.
 The prevalence of urinary tract stonedisease is estimated to be
2% to 3%.
Rare in Blacks; Commoner in Whites and Asians
The likelihood that a white man will develop stone disease by
age 70 years is about 1 in 8.
The recurrence rate without treatment for calcium oxalate renal
stones is about
10% at 1 year
35% at 5 years, and
50% at 10 years
Male : Female ratio is 3:1
Peak at 20-40 years old
Ingestion of excessive amounts of purines ,oxalates,calcium,
phosphate, and other elements often results in excessive
excretion of these components in urine
A low fluid intake, with a subsequent low volume of urine
production, produces high concentrations of stone-forming
solutes in the urine.
This is an important environmental factor in stone formation.

Disease associated with stone
formation:
Hyperparathyroidism
renal tubular acidosis
(partial/complete)
jejunoileal bypass
Crohns disease,
intestinal resection
malabsorptive conditions
sarcoidosis
Hyperthyroidism
Anatomical abnormalities associated with
stone formation:
tubular ectasia (medullary sponge
kidney)
pelvo-ureteral junction obstruction
calix diverticulum
calix cyst
ureteral stricture
vesico-ureteral reflux
horseshoe kidney
ureterocele

Medication associated with stone

formation:
calcium supplements
vitamin D supplements
Acetazolamide
ascorbic acid in megadoses ( > 4
g/day),
Sulphonamides
Triamterene
indinavir
Penyebab:
Urin sangat pekat, stasis urine
Ketidakseimbangan pH urin
Asam: asam urat dan Crystine Stones
Stones Kalsium: Alkaline
gout
hiperparatiroidisme
inflamasi usus
ISK
obat
Lasix, Topamax, Crixivan
 Kalsium Oksalat
paling sering
Kalsium Fosfat
Struvite
Lebih sering terjadi pada wanita dibandingkan pria.
Umumnya akibat dari ISK.
Asam Urat
Disebabkan oleh konsumsi tinggi protein dan asam
urat.
Cystine
Cukup jarang; umumnya terkait dengan keturunan
 Calcium Stones 70-80%
Ca Phosphate 5-10%
Ca Oxalate/Phosphate 30-45% (Mixed)
Ca Oxalate 20-30%
Struvite stones 15-20%
Cystine stones -3%
Uric acid stones
Oxalate (Calcium Oxalate)
Also Called Mulberry Stone

Covered With Sharp Projections

Sharp Makes Kidney Bleed (Haematuria)

Very Hard

Radio Opaque

Under microscope looks like Hourglass or Dumbbell

shape if monohydrate and Like an Envelope if Dihydrate
Phosphate stones
Usually Calcium Phosphate
Sometimes Calcium Magnesium Ammonium Phosphate Or
Triple Phosphate
Smooth Minimum Symptoms
Dirty White
Radio Opaque
Calcium Phosphate also called Brushite appears like Needle
shape under microscope
In Alkaline urineEnlarges rapidlyTake the shape of
CalycesStaghorn
Uric Acid & Urate Stone
Hard & Smooth

Multiple

Yellow or Red-brown

Radio - Lucent (Use Ultrasound)

Under microscope appear like irregular plates or

rosettes
Cystine Stone
Autosomal recesive disorder

Usually in Young Girls

Due To Cystinuria -
Cystine Not Absorbed by Tubules
Multiple
Soft or Hard can form stag-horns
Pink or Yellow
Radio-opaque
Under
ring microscope appears like hexagonal or benzene
 Gejala paling sering: Tambahan:
Nyeri pinggang Adanya ISK
Nyeri perut Demam atau menggigil
Mual dan muntah Nyeri di selangkangan,
Kelelahan labia atau testis
Peningkatan suhu, BP, dan Bau urin - busuk
pernapasan Disuria
Data obyektif: berkeringat,
mencengkeram perut.
Nyeri hebat: mondar
mandir
Kebanyakan pinggang kiri
 Renal/Ureteral Colic (PAIN)
Abrupt onset while asleep or at rest
Crescendo of extreme pain
Flank radiating laterally and downward to
groin/testicle or round ligament/labia majora
Impossible to be still
Mid ureter
lateral flank and abdomen
Lower ureter
suprapubic and urethral
urgency and frequency
 GI Symptoms
Nausea and vomiting autonomic n.s.
Ileus or diarrhea
DDX: gastroenteritis, appendicitis, colitis,
diverticular disease and salpingitis
Hematuria
gross or microscopic
15% no hematuria!
Pyuria/Fever
Pyuria even without infection
Infection especially in females
 History
Duration, characteristics, and location of pain
History of urinary calculi
Prior complications related to stone manipulation
Urinary tract infections
Loss of renal function
Family history of calculi
 Riwayat keluarga
Pengobatan saat ini
Frekuensi buang air kecil
Apakah pasien mengalami nyeri saat kencing?
Apa makanan khas pasien?
Bagaimana pasien mengatasi batu ginjal di
masa lalu?
 Faktor-Faktor Risiko: Faktor risiko tambahan:
Riwayat pengobatan Riwayat Keluarga
Jenis kelamin (laki-laki)
Riwayat 3 kali serangan
batu ginjal Umur (20-55)
Ras (Caukasian)
Dehidrasi / Kekurangan
Konsumsi:
Cairan
Tinggi natrium
Paparan Tinggi protein
Buruh Makanan tinggi oksalat
Pekerja lapangan Vit A / D, jus jeruk
Cuaca / Iklim Lifestyle
Yang Panas, kering Obesitas
Hipertensi
 BUN:
Dewasa :
5 25 mg/dl

Creatinine:
Dewasa:
0,6-1,3 mg/dl.

Urine Analysis
https://www.clevelandclinic.org/heartcenter/images/guide/tests/lab.gif
http://www.ganfyd.org/images/f/fb/Dipstick_bottle.jpg
 Test and Diagnostic:
Analisa Blood
Analisa Urine
CT Scan
Foto Ro Abdominal
USG
Retrograde Pyelogram
Cystoscopy
Intravenous pyelography

http://knol.google.com/k/-/-/PYwIQr_i/GXb8Fg/Stone%20CT.jpg
 Urinalysis- haematuria ~ 85% of pts
FBP
elevated WBC = renal/ systemic inf.
low RBC= xnic dse/ sev. haematuria
serum eletrolytes, creatinine, calcium, uric acid,
phosphorus: to asses renal function and
metabolic risk factors for stone formation
24 hr urine collection for pH, Ca, oxalate, uric
acid, Na, phosphorus, citrate, magnesium,
creatinine and total volume
 Plain abdominal radiograph
KUB for assessing total stone burden, the size, shape,
and location of urinary calculi in some patients.
Calcium-containing stones (~85% of all upper urinary
tract calculi) are radiopaque,
Pure uric acid, indinavir-induced, and cystine calculi
are relatively radiolucent on plain radiography
Renal ultrasound
IVP
determine the size & location
anatomical & functional assessment
Helical CT-scan without contrast
 CALCULUS IN LT
KIDNEY LOWER POLE
STAGHORN CALCULUS
 Nyeri b.d obstruksi akut batu ginjal ditandai
dengan pasien mondar-mandir di ruangan,
dan pasien menyampaikan secara verbal
adanya nyeri saat pengkajian.

Tujuan: Pasien menyatakan rasa sakit

berkurang dalam waktu 2 jam dari
penerimaan.
 Berikan obat nyeri sesuai resep dokter.

Latih teknik non-farmasi seperti guided imagery dan /

atau meditasi untuk menghilangkan rasa sakit.

Pasien dapat mengelola tingkat nyerinya.

Pasien dapat menyampaikan fokus perhatiannya atau rasa

takutnya yang mungkin berhubungan dengan nyeri.

Memberikan dukungan emosional bagi pasien.

Menilai kembali tingkat nyeri pasien dalam waktu 1 jam

setelah pemberian obat nyeri
 Defisit pengetahuan b.d kurangnya informasi
tentang kebutuhan cairan dan asupan diet
ditandai dengan terjadinya batu ginjal
Tujuan: Pasien memahami bagaimana mencegah
terjadinya batu ginjal dibuktikan dengan adanya rencana
perawatan untuk mencegah terjadinya kembali batu
ginjal.

Risiko infeksi b.d stasis urin akibat obstruksi

batu ginjal di saluran kemih.
Tujuan: urine Pasien akan bening/kuning jernih, pasien
tidak mengalami demam, tidak terdapat indikasi ISK atau
infeksi lainnya.
 Dua fokus tindakan:
Pengobatan masalah akut, seperti nyeri,
neurovaskuler, dll
Mengidentifikasi penyebab dan mencegah
terbentuknya batu ginjal lebih lanjut

Pengobatan masalah akut:

Pengobatan Nyeri
Menjaga asupan cairan
Pembatasan diet
Dukungan emosional
Prosedur invasif (mungkin diperlukan)
MEDICAL

SURGICAL
 The cornerstone of management of ureteral colic is analgesia
Morphine sulfate is the narcotic analgesic drug of choice for
parenteral use.
Antiemetic agents [metoclopramide ] may also be added as
needed.
The calcium channel blocker[ nifedipine] relaxes ureteral
smooth muscle and enhances stone passage
The alpha blockers, [ terazosin], also relax musculature of the
ureter and lower urinary tract, markedly facilitating passage
of ureteral stones
Uric acid and cystine calculi can be dissolved with medical
therapy
stones are dissolved with alkalinization of the urine.
Sodium bicarbonate can be used as the alkalinizing agent
 High Fluid Intake and Alkalinized Urine dissolve
most of the smaller cystine stones
D-Pencillamine or MPG (Mercaptopropionylglycine)
binds to cystine that is soluble in urine
Side effects of Pencillamine restricts it use
Allergic rashes, GI problems- Nausea, Vomiting,
Diarrhoea
MPG better tolerated
Large obstructive stones Surgery required first
 Lithotripsy: digunakan untuk memecah batu
menjadi fragmen yang lebih kecil agar dapat
melewati saluran kemih.
Extracorporeal Shock-Wave (ESWL)
Percutaneous Ultrasonic
Electrohydraulic
Laser
Terapi Bedah
Nephrolithotomy (Ginjal)
Pyelolithotomy (Renal Pelvis)
Ureterolithotomy (ureter)
ExtracorporealShock Wave Lithotripsy (ESWL)
Percutaneous Nephrolithotomy (PNL)
Ureteroscopy
Open surgery

Choice of approach depends on stone burden

(size and number), stone composition, and
stone location.
 Shock waves generated under water can travel through body
without any appreciable loss of energy.
When they encounter stones, the changes in density causes
energy to be absorbed and reflected by the stone.
This results in fragmentation of the stones.

Before lithotripsy the stone is localized by either Ultrasound

or Flouroscopy.
Complications:
Haematuria is quite common (hemorrhage and edema
within or around the kidney)
Incomplete stone Fragmentation & Obstruction;
Stienstrasse ( stone street ) usually due to a large
Leading fragment ( Stents Recommended prior to ESWL for
Calculi > 1.5 cm )
 Percutaneous approach allows stone removal with less
morbidity, shorter convalescence, and reduced cost compared
with open techniques
PNL has replaced open surgical procedures for removal of
large or complex renal calculi at most institutions
PNL can be performed with general, epidural, or local
anesthesia
The kidney should be approached from below the 12th rib to
reduce the risk of pleural complications
The position of the retroperitoneal colon is usually anterior or
anterolateral to the lateral renal border. Therefore, risk of
colon injury is minimal
The liver and spleen may also be at risk of injury during
percutaneous access. However, in the absence of
splenomegaly or hepatomegaly, injury to these organs is
extremely rare with a puncture below the 12th rib
Once the point of puncture and the preferred calyx have been
selected, a C-arm fluouroscope is entered. The tract is dilated
by special dilators
The urologist can proceed with stone removal using
endoscopic techniques e.g with Randall's forceps, a grssper or
stone baskets under fluoroscopic guidance
 There is a concurrence in the literature regarding the need for
postoperative drainage with a nephrostomy tube after
percutaneous procedures.
The main function of a nephrostomy tube is the drainage of
urine and possibly the tamponade of bleeding originating
from the structures acutely expanded during dilatation.

URETEROSCOPY:
A ureteroscope is passed through the ureteral orifices
It is performed under general or regional anaesthesia
Once the stone is visualized, fragmentation with of the stone
can be done with laser, or mechanically
If significant ureteral edema or manipulation occurs, a stent
should be placed to prevent colic and obstruction
 Generally indicated for large stones that would
require multiple ESWL or PNL
obese patients are poor candidates for ESWL and
may be difficult to manage with PNL; Open surgery
might be the best option
Open surgery may be
Pyelolithotomy
Nephrolithotomy
Ureterolithotomy
Cystolithotomy
 Depending on the location of the stone, various
procedures are done for stone extraxtion
In the kidney
ESWL
PNL
Open methods
Pyelolithotomy for a stone in the extrarenal pelvis
Nephrolithotomy for a stone deep into the renal parenchyma
Partial nephrectomy if there is a stone impacted into the lower
most calyx
In the ureter
Upper ureter: ESWL is ideal
Mid ureter: ESWL, ureteroscopy or ureterolithotomy
Lower Ureter: Ureteroscope or ureterolithotomy
 In the Bladder
Litholapaxy:
through a cystoscopy, the stone is grasped firmly and
broken. Small fragments are evacuated by evacuator
Suprapubic cystolithotomy
if the stone is too big or too hard
 Ureteral scarring and stenosis
Nidus for infectionserious infection of the
kidney that diminishes renal function
Urinary fistula formation
Ureteral perforation
Extravasation
Urinary outflow obstruction
hydronephrosisCRF
 High Fluid Intake
Restrict Salt
Avoid high intake of purine food
Increased citrus fruits may help
If hypercalciuria restrict Ca intake
 Pendidikan pasien
hidrasi
Minum 2-3 liter cairan per hari (14 gelas)
air
Lemon (asam sitrat dapat mencegah pembentukan
batu)
Konsumsi diet
Rendah sodium/natrium
Kurangi makanan mengandung oksalat
Rendah protein
Latihan/Meningkatkan Kegiatan
Pengobatan segera
 Tujuan: Menentukan efektivitas suplemen herbal
yang terbuat dari Varuna dan batang pisang,
"Herbmed," pada batu ginjal
Sampel: 77 pasien random, menggunakan plasebo,
dilakukan di India dari bulan Juli 2007 hingga
Februari 2008. Dua kelompok dibentuk: Grup A
dengan d. batu 5-10mm dan Grup B dengan d. batu
> 10mm.
Hasil: Pasien yang mengurangi suplemen herbal
menunjukkan pengecilan sebesar 33% ukuran batu
ginjal.
Kesimpulan: Herbmed adalah pengobatan herbal
yang mungkin memiliki efek yang menjanjikan dalam
mengurangi ukuran batu ginjal.
 Tujuan: Untuk menentukan kemungkinan peran
fruktosa dalam pembentukan batu ginjal.
Sampel: Peneliti melihat tiga kohort yang berbeda
(wanita tua, wanita yang lebih muda, dan laki-
laki).
Hasil: Hasil dari penelitian menunjukkan bahwa
ada korelasi positif antara asupan fruktosa dan
pembentukan batu ginjal.
Kesimpulan: Asupan fruktosa dapat
meningkatkan resistensi insulin yang
menurunkan pH dalam urin dan meningkatkan
resiko pembentukan batu ginjal akibat kadar
asam urat yang meningkat.
50