NEPHROLYTHIASIS

UROLITHIASIS
Calvin Damanik, Dr, SpPD
Departement Penyakit Dalam Fak Kedokteran UMI Medan
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%
MEDICAL OPTIONS DURING EXPECTANT
MANAGEMENT
 Pain control
 AB prophylaxis
 Alpha blockers
 Ca channel blockers
 steroids
 ESWL
- imaging : fluoroscopy
- anesthesia : sedation or general
- potential long-term renal effect :
renal injury/scar, hypertension
- complications :
hematoma (<1%) UTI/sepsis
obstruction injury to organ
- contraindications :
pregnancy calcified aneurysm
morbid obesity bleeding diathesis
 Ureteroscopy
 Percutaneous nephrolithotripsy
ESWL : Extra Corporeal Shock
Wave Lithotripsy
Sebelum ESWL
Foto setelah ESWL
Foto setelah ESWL
STONE FREE RATES

proximal distal
ureter ureter
<1.0 cm
ESWL 84% 85%
Ureteroscopy 56% 89%
PCNL 76% -
≥1.0 cm
ESWL 72% 74%
Ureteroscopy 44% 73%
PCNL 74% -
STONE FRAGMENTATION TECHNOLOGIES

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