URETEROLITHIASIS

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Urolithiasis

• Urinary tract stones (urolithiasis) is the presence of stones in the

urinary tract, starting from the kidneys to the urethra.
• The third largest disease in urology.(After urinary tract infections and
pathologic conditions of the prostate)
 CLASSIFICATION OF
Based on Location)
STONE

BATU GINJAL
(nefrolithiasi
s)

BATU URETER
(ureterolithiasi
s)

BATU BULI
(vesikolithiasis)
BATU URETRA
(uretrolithiasis
)
EPIDEMIOLOGY
- Prevalance of Urolithiasis in Asia 1-19%
- Prevalance kidney stones in Indonesia 0,6%
- The highest prevalence on age 55-64 (1,3%)
- The ratio man : woman is 2 : 1 , where is man 0,8% and woman 0,4 %
 Predisposition factor

1. Gender
Stone disease typically affects adult men more commonly than adult women. By a
variety of indicators including inpatient admissions, outpatient office visits, and
emergency department visits, men are affected two to three times more often than
women

2. Race
Among U.S. men found the highest prevalence of stone disease in whites,
followed by Hispanics, Asians, and African-Americans, who had prevalences of 70%,
63%, and 44% of whites, respectively.

2. Age
Stone occurrence is relatively uncommon before age 20 but peaks in incidence in the
fourth to sixth decades of life
 Predisposition factor

3. Geography
The geographic distribution of stone disease tends to roughly follow environmental risk
factors; a higher prevalence of stone disease is found in hot, arid or dry
climates such as the mountains, desert, or tropical areas

4. Climate
The highest incidence of stone disease in the summer months, July through
September, with the peak occurring within 1 to 2 months of maximal mean
temperatures

5. Occupation
Heat exposure and dehydration constitute occupational risk factors for stone
disease as well. Cooks and engineering room personnel, both of whom are exposed to
high temperatures, were found to have the highest rates of stone formation among
personnel of the Royal Navy
 Predisposition factor

6. Body Mass Index and Weight

- The prevalence and incident risk of stone disease were directly correlated with
weight and body mass index (BMI) in both sexes, although the magnitude of the
association was greater in women than men.
- Subjects with higher BMI excreted more urinary oxalate, uric acid, sodium, and
phosphorus than those with lower BMI. Furthermore, similar to other studies, urinary
supersaturation of uric acid increased with BMI.

7. Water
The beneficial effect of a high fluid intake on stone prevention has long been
recognized. In two large observational studies, fluid intake was found to be inversely
related to the risk of incident kidney stone formation
PHYSICOCHEMIST
RY AND
PATHOGENESIS
State of saturation
 COMMON TYPES OF KIDNEY
Calcium oxalate STONE
• Calcium phosphate concretion (called a Randall’s
plaque- highlighted by the arrows below), erodes
through the urothelium and is a nidus for CaOx
deposition.
• Risk factors: Dehydration, hypercalciuria,
hyperoxaluria, hypernatrituria, hyperuricosuria.
• Urinary citrate is an important inhibitor of CaOx
deposition.
Uric Acid Stones
• Persistently acidic urine
• Persistent metabolic acidosis (eg renal tubular acidosis)
• Hyperuricosuria due to a variety of causes Lymphoma/ leukemia treated with
chemotherapy
• Hyperuricemia (gout)

Parallelogram shape
Struvite Stones
• Also called magnesium
ammonium phosphate stone
• Caused by UTIs with urease-
producing organisms Commonly
Proteus
• E. Coli is not urease-producing
• Urea  NH4 + OH- (raises urine
pH)
• Can form staghorn calculi
which occupy the calyceal
spaces/ internal renal
volumetric capacity
Cystine Stones
• Amino acid of
cysteineS-S-cysteine
• One of the 4 dibasic
amino acids including
ornithine, lysine, and
arginine (COLA)
• Cystine stones
produced in patients
homozygous for
recessive cystine
transport gene Hexagonal shape
• Forms in acidic urine
Clinical Manifestation of Ureterolithiasis
• Colic pain, akibat peristaltik yang sifatnya hilang timbul
• nausea
• Pain over
 Upper

Ureterolithiai
s
Mid

Distal
 URETEROLITHIAS
IS

The statistical
There are three narrowing along the probability of
spontaneous ureteral
ureter which is usually the place stone passage is
where the stone stops coming directly related to the
distance of the ureter
down : to be traversed and
1. Ureteropelvic junction (UPJ) inversely related to
stone size.
2. Cross ureter with vasa iliaka Morse and Resnick
3. Ureterovesical junction (UVJ) (1991) reported that
the rate of
spontaneous passage is
greater for distal
ureteral stones (71%)
than for proximal
ureteral stones (22%).
 Upper and Mid Ureter

• Often cause severe, sharp back (costovertebral angle) or flank pain.

• The pain may be more severe and intermittent if the stone is
progressing down the ureter and causing intermittent obstruction
• The pain of upper ureteral stones thus radiates to the lumbar
region and flank.
• Midureteral calculi tend to cause pain that radiates caudally and
anteriorly toward the mid and lower abdomen in a curved, band-like
fashion. This band initially parallels the lower costal margin but deviates
caudad toward the bony pelvis and inguinal ligament. The pain may
mimic acute appendicitis if on the right or acute diverticulitis if on the
left side
 Distal Ureter

• Calculi in the lower ureter often cause pain that radiates to the groin or
testicle in males and the labia majora in females. This referred pain is
often generated from the ilioinguinal or genital branch of the genitofemoral
nerves.
• Stones in the intramural ureter may mimic cystitis, urethritis, or prostatitis
by causing suprapubic pain, urinary frequency and urgency, dysuria,
stranguria, or gross hematuria. Bowel symptoms are not uncommon.
• In women, the diagnosis may be confused with menstrual pain, pelvic
inflammatory disease, and ruptured or twisted ovarian cysts.
• Strictures of the distal ureter from radiation, operative injury, or previous
endoscopic procedures can present with similar symptoms. This pain pattern
is likely due to the similar innervation of the intramural ureter and bladder.
 Symptoms & Signs at Presentation

PAIN
• Upper-tract urinary stones usually eventually cause pain. The
character of the pain depends on the location. Calculi small
enough to venture down the ureter usually have difficulty passing
through the ureteropelvic junction, over the iliac vessels, or
entering the bladder at the ureterovesical junction.
• In the ureter, however, local pain is referred to the
distribution of the ilioinguinal nerve and the genital branch
of the genitofemoral nerve, whereas pain from obstruction is
referred to the same areas as for collecting system calculi (flank
and costovertebral angle), thereby allowing discrimination.
• The vast majority of urinary stones present with the acute
onset of pain due to acute obstruction and distention of the
upper urinary tract.
• Small ureteral stones frequently present with severe pain,
while large staghorn calculi may present with a dull ache or flank
discomfort.
Figure 16–7. Radiation of pain with various
types of ureteral stone.
Upper left: Ureteropelvic stone. Severe
costovertebral angle pain from capsular and
pelvic distention; acute renal and urethral
pain from hyperperistalsis of smooth muscle
of calyces, pelvis, and ureter, with pain
radiating along the course of the ureter (and
into the testicle, since the nerve supply to
the kidney and testis is the same.) The
testis is hypersensitive.
Upper right: Midureteral stone. Same as
above but with more pain in the lower
abdominal quadrant.
Left: : Low ureteral stone. Same as
described earlier, with pain radiating into
bladder, vulva, or scrotum. The scrotal wall
is hyperesthetic. Testicular sensitivity is
absent. When the stone approaches the
bladder, urgency and frequency with
burning on urination develop as a
result of inflammation of the bladder
wall around the ureteral orifice.
B. HEMATURIA
A complete urinalysis helps to confirm the diagnosis of a
urinary stone by assessing for hematuria and crystalluria and
documenting urinary pH. Patients frequently admit to intermittent
gross hematuria or occasional tea-colored urine (old blood). Most
patients will have at least microhematuria. Rarely (in 10–15% of
cases), complete ureteral obstruction presents without
microhematuria.
C. INFECTION
Infection may be a contributing factor to pain perception.
Uropathogenic bacteria may alter ureteral peristalsis by the
production of exotoxins and endotoxins. Local inflammation from
infection can lead to chemoreceptor activation and perception of
local pain with its corresponding referral pattern.
D. ASSOCIATED FEVER
The association of urinary stones with fever is a relative
medical emergency. Signs of clinical sepsis are variable and
include fever, tachycardia, hypotension, and cutaneous vasodilation.
Costovertebral angle tenderness may be marked with acute
upper-tract obstruction; however, it cannot be relied on to be
present in instances of longterm obstruction.
E. NAUSEA AND VOMITING

Upper-tract obstruction is frequently associated with nausea and vomiting.

 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.
 PHYSICAL EXAMINATION

• Costovertebral angle tenderness may be apparent. An abdominal

mass may be palpable in patients with long-standing obstructive urinary
calculi and severe hydronephrosis.
 IMAGING

a. Computed tomography
Noncontrast spiral CT scans are now the imaging modality of choice in patients
presenting with acute renal colic.
b. Intravenous pyelography
An IVP can simultaneously document nephrolithiasis and upper-tract anatomy. It
is rarely used today with the widespread availability of CT scan and ultrasound.
c. Tomography
d. KUB films and directed ultrasonography
A KUB film and renal ultrasound may be as effective as an IVP or CT scan in
establishing a diagnosis.
e. Retrograde pyelography
Retrograde pyelography occasionally is required to delineate upper-tract
anatomy and localize small or radiolucent offending calculi.
f. Magnetic resonance imagin
Magnetic resonance imaging is a poor study to document urinary stone disease.
 TREATMENT
• For patient with stone of ≤5 mm  conservative management
• The goal of the surgical treatment of patients suffering from ureteral
calculi is to achieve complete stone clearance with minimal attendant
morbidity.
• Conservative Observation
Most ureteral calculi pass and do not require intervention. Spontaneous passage depends on
stone size, shape, location, and associated ureteral edema (which is likely to depend on the
length of time that a stone has not progressed). Ureteral calculi 4–5 mm in size have a 40–
50% chance of spontaneous passage. In contrast, calculi >6 mm have a >15% chance of
spontaneous passage. This does not mean that a 1-cm stone will not pass or that a 1- to 2-
mm stone will always pass uneventfully.
• Relief of Obstruction
Urinary stone disease may result in significant morbidity and possible mortality in the
presence of obstruction, especially with concurrent infection. A patient with obstructive
urinary calculi with fever and infected urine requires emergent drainage. Retrograde
pyelography to define upper-tract anatomy is logically followed by retrograde placement of a
double-J ureteral stent.
• Extracorporeal Shock Wave Lithotripsy
Extracorporeal SWL has revolutionized the treatment of urinary stones.
The concept of using shock waves to fragment.
• Percutaneous Nephrolithotomy
Percutaneous removal of renal and proximal ureteral calculi is the
treatment of choice for large (>2.5 cm) calculi; those resistant to SWL;
select lower pole calyceal stones with a narrow, long infundibulum and
an acute infundibulopelvic angle; and instances with evidence of
obstruction; the method can rapidly establish a stone-free status
• Open Stone Surgery
Open stone surgery is the historic way to remove calculi, yet it is rarely
used today. The morbidity of the incision, the possibility of retained stone
fragments, and the ease and success of less invasive techniques have
made these procedures rare.

• Ureterolithotomy
Long-standing ureteral calculi—those inaccessible with endoscopy and
those resistant to SWL—can be extracted with an ureterolithotomy.
General Dietary Guidelines
• Increase fluid intake & low salt diet – reduces the
likelihood of stone supersaturation
• Moderate animal protein – regulates uric acid
• Moderate calcium – a certain amount of calcium is
needed in the diet to bind oxalate and prevent
hyperoxaluria
• Increased dietary citrate- found in lemons and
oranges; a major buffer for urinary pH