URINARY LITHIASIS

EVALUATION AND TREATMENT

References
DIAGNOSIS
History
Physical examination
Additional :
 Urine, microbiology
 Serum : kidney function, uric acid
 Plain x-ray / USG /IVP
 Recently : Computed tomography (CT), Magnetic
resonance imaging (MRI), and endourology
HISTORY
Important to make patient feels comfort

Time is essential. Focus the discussion to make it as

productive and informative as possible

A complete history can be divided into the chief

complaint and history of the present illness, the patient's
past medical history, and a family history
HISTORY

The chief complaint is a constant reminder to

the urologist as to why the patient initially
sought care

In obtaining the history of the present illness,

the duration, severity, chronicity, periodicity,
and degree of disability are important
considerations
Metabolic Stone Evaluation

Why ???
The incidence of nephrolithiasis is increasing
especially in female
Up 50% risk of recurrence within the subsequent 10
years after first-time stone formers
A metabolic evaluation may not be economically
sound if it is applied to all patients with stone
disease …… But…..
A simplified metabolic evaluation has been
established
…….. So What The Indications??
  Indications for a Metabolic Stone Evaluation
 Recurrent stone formers  
  Strong family history of stones   
 Intestinal disease (particularly chronic diarrhea)   
 Pathologic skeletal fractures  
  Osteoporosis   
 History of urinary tract infection with calculi   
 Personal history of gout   
 Infirm health (unable to tolerate repeated stone episodes)
   Solitary kidney
    Anatomic abnormalities  
   Renal insufficiency   
 Stones composed of cystine, uric acid, or struvite
 Basic Metabolic Evaluation
 HISTORY : Hyperparathyroidism or hypercalcaemia, Hyperuricemia, Renal
tubular acidosis
 X-RAY
 STONE ANALYSIS : Ca, MAP, Uric Acid, Cystein, Carbonate etc.
 BLOOD:
• SERUM CREATININE
• CALCIUM
• URIC ACID
 URINE:
• Urinary sediment/dipstick test for:
Red cells
White cells
Bacteriuria (nitrite)
Urine culture in case of a possible bacteriuria
pH
 CLINICAL PRESENTATION

 PAIN

Classically : flank pain, often acute in

onset.
Located in the ipsilateral costoverteral
angel
Caused by distension of renal capsule
May radiated to upper abdomen,
umbilicus, testis or labium
Pain by ureteral obstruction is typically colicky in
nature and intensifies with ureteral peristalsis

-
PAIN

 Associated with gastrointestinal symptoms

 Ureteral pain is usually acute and secondary to obstruction
 Site of ureteral obstruction  different referred pain
 Right mid ureteral stone - McBurney”s point
Distal ureteral stones  ipsilateral groin,
testicular (can mimic torsion or
epididimytis), vulvar pain, supra pubic, urethra and tip of penis
PAIN

- waxes & wanes

- frequently move about to find a more
comfortable position

 Sudden onset, no relief with change of position

CLINICAL PRESENTATION
 Nausea & vomiting
 Irritative voiding symptom
 Hematuria (gross or microscopic)
 Urinary infection
 Fever, esp if infection present
 Occasionally asymptomatic, with stones
detected incidentally
PHYSICAL EXAMINATION
.Inspection : general overview of patient
local - position ??
systemic component  tachycardia,
sweating and nausea
Palpation : Bimanual palpation of the kidney
 abdominal mass
DRE : To exclude other patological conditions
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
 Non-contrast computed tomography
- 97% sensitive & 97% specific for stone
- 4 signs of obstruction :
hydroureter
perinephric stranding
hydronephrosis
nephromegaly
Imaging modalities
Preference Examination LE
number
1. Non-contrast CT 1

2. Excretory urography Standard

(IVP) Procedure
3.. KUB + USG 2a
ACUTE MANAGEMENT

 Pain control : - narcotics

- NSAIDS
 IV fluids
 AB if urinary infection (+)
 Strain urine
 Recommended indication for admission :
- uncontrolled pain
- unremitting nausea/vomiting with inability to
tolerate PO
- obstructed, infected renal unit
- obstructed, solitary renal unit
- bilateral obstruction
- anuria
Pain relief for patients with acute
stone colic

Pharmacological agent LE

1. Diclofenac sodium 1b
2. Indomethacin 1b
Ibuprofen
3. Hydromorphine 4
hydrochloride (+
atropine)
Methamizol
Pentazocine
Tramadol
 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
INDICATIONS FOR ACTIVE
STONE REMOVAL
 The stone diameter is > 7 mm (because of a low
rate of spontaneous passage)
 Pain relief cannot be achieved
 Stone obstruction associated with infection
 Pyonephrosis or urosepsis
 In single kidneys with obstruction
 Bilateral obstruction
SURGERY
 ESWL
 Ureteroscopy
 Percutaneous nephrolithotomy (PNL)
 Laparascopy
 Open surgery
SURGERY
 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
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
THANK YOU