UROLITHIASIS

Dr. dr. Kadek Budi Santosa, Sp.U(K)

UDAYANA UNIVERSITY, UROLOGY DEPARTMENT
PROF IGNG NGOERAH HOSPITAL
PROBLEMS

1. Urolithiasis are common

2. High recurrence rate
3. No appropriate metabolic evaluation
4. Poor compliance with medical and diet
regimens
Surgical Management in Urology (5
year period at Sanglah hospital)
Total : 4276
800
722

600 585
516 531
496

400 endourology
286 288 283 299 open surgery
270
Column1
200

0
2006 2007 2008 2009 2010
Urology (5 year period at Sanglah hospital)
Total : 4276

▪ Uropathy obstructive 3335 (78%)

CAUSE
●Urolithiasis 59%
●BPH 23%
●Malignancy 8%
●Lain2 10%
KIDNEY TRANSPLANT PROF IGNG NGOERAH
Urolithiasis
EPIDEMIOLOGY
AND RISK
FACTOR
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EPIDEMIOLOGY AND RISK FACTOR

6th Decade
Caucasian Anatomical & Drug-Induce
Obesity functional Systemic disease
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Abnormalities

Prevalence : 1 – 20% depends on geographic factor,

ethnic, climate, dietary and genetics

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Campbell, M.F., Kavoussi, L.R. and Wein, A.J. (2012) Campbell-Walsh Urology. 10th Edition, Elsevier Saunders, Philadelphia, PA.
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 URINARY TRACT STONE

Age Profession Nutrition Climate Inheritance

Sex Constitution Race

Abnormal renal Disturbed Urinary Metabolic Genetic

morphology urine flow tract infection abnormalities factors

Increase Decreased

excretion of excretion of Excretion of Urinary volume

stone forming crystallization crystallization
constituents promoters inhibitors

Physico-chemical change in the

state of supersaturation

Abnormal crystalluria
Crystal aggregation
Crystal growth
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CLASSIFICATION
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CLASSIFICATION
Stone Location
Etiology of formation
Composition
X-ray characteristics

Campbell, M.F., Kavoussi, L.R. and Wein, A.J. (2012) Campbell-Walsh Urology. 10th Edition, Elsevier Saunders, Philadelphia, PA.
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CLASSIFICATION
Location
Renal à Calyx and Pelvis
Ureter à Proximal, Middle, Distal
Bladder
Urethra à Anterior and Posterior

Campbell, M.F., Kavoussi, L.R. and Wein, A.J. (2012) Campbell-Walsh Urology. 10th Edition, Elsevier Saunders, Philadelphia, PA.
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CLASSIFICATION
Etiology
2 groups:
1. MIAF: definitive causes:

n M : Metabolic
n I : Infection
n A : Anatomic
n F : Functional

2. Idiopathic
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CLASSIFICATION
Stone composition
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CLASSIFICATION
X-Ray characteristic
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PATHOGENESIS
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PATHOGENESIS
HYPERCALCIURIA
3 types of Hypercalciuria
1. Absorptive/intestinal
2. Resorptive/Bone
3. Leak/Renal

Campbell, M.F., Kavoussi, L.R. and Wein, A.J. (2012) Campbell-Walsh Urology. 10th Edition, Elsevier Saunders, Philadelphia, PA.
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PATHOGENESIS
HYPERCALCIURIA

Campbell, M.F., Kavoussi, L.R. and Wein, A.J. (2012) Campbell-Walsh Urology. 10th Edition, Elsevier Saunders, Philadelphia, PA.
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PATHOGENESIS
HYPEROXALATURIA

Oxalate Intestinal Absorption

Modulated by Oxalate diet and
calcium intake
O. Formigenes
Chronic Diarrhea
Fat Malabsorption
Campbell, M.F., Kavoussi, L.R. and Wein, A.J. (2012) Campbell-Walsh Urology. 10th Edition, Elsevier Saunders, Philadelphia, PA.
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PATHOGENES
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IS
Hyperuricosuria Cystinuria Xanthineuria
Purine metabolic à Disorder amino Type I: xanthine
Uric Acid acid transport oxidoreductase (XO)
C ystine deficiency
A rginine Type II: aldehyde oxidase +
L ysine XO
O rnithine

Campbell, M.F., Kavoussi, L.R. and Wein, A.J. (2012) Campbell-Walsh Urology. 10th Edition, Elsevier Saunders, Philadelphia, PA.
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PATHOGENES
Infection Stone
IS
1. Ascending Urinary Tract Infection

2. Urea-splitting bacteria
Urea à ammonia (Ammoniuria) à rapid formation of an
Proteus Mirabilis, “infectious” calculus à mineralized à dense stone
Klebsiella spp.
Pseudomonas spp.
Morgagni, Bacteria trapped within the stone à recurrent urinary tract
Acinetobacter, infections à classic staghorn calculus
Staphylococcus spp,
Enterobacter
Proteus sp. Klebsiella sp. Pseudomonas sp.

Campbell, M.F., Kavoussi, L.R. and Wein, A.J. (2012) Campbell-Walsh Urology. 10th Edition, Elsevier Saunders, Philadelphia, PA.
DIAGNOSIS
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DIAGNOSIS
DIAGNOSIS
Anamnesis and Physical Examination

Laboratory

Radiology
Anamnesis and Physical Examination

Most common symptoms

• Flank pain (somatic)
• Radiating pain/colic (autonom)
• Nausea
• Dysuria
• Hematuria
Anamnesis and Physical Examination
 Anamnesis and Physical Examination

GENERAL STATUS : Sepsis

LOCAL STATUS (inspection, palpation, percussion,

auscultation)
Regio Flank
Regio Suprapubic
Regio Genitalia
RECTAL touche
LABORATORY DIAGNOSIS
Blood Analysis
• CBC
• Creatinine
• Uric Acid
• Calcium + PTH
• BGA +Electrolyte
Urine Analysis
RADIOLOGY DIAGNOSIS

• BOF/KUB
• USG (Primary)
• IVP
• CT-Scan Non-contrast (NCCT)
• CT scan with contrast
RADIOLOGY
USG (Primary)
 DIAGNOSIS

NCCT

Determine non opaque/radiolucent stone, stone size,

density and location, skin to stone distance, anatomy
structure, another cause of abdominal pain
Urolithiasis Guidelines. Netherlands: European Association of Urology. [cited 2023 March 18]. Available from: https://uroweb.org/guidelines/urolithiasis
 Advantage Of NCCT ??

KUB/BOF USG NCCT

 DIAGNOSIS

CT-Scan Non-contrast (NCCT)

• GOLD STANDARD
• Sensitivity 96,6%, Specificity 94,9%
• BOF & IVP are not recommended if NCCT available

Urolithiasis Guidelines. Netherlands: European Association of Urology. [cited 2023 March 18]. Available from: https://uroweb.org/guidelines/urolithiasis
 DIAGNOSIS
Anamnesa and physical examination

LABORATORY

USG (primary diagnostic tool)

NCCT

Urolithiasis Guidelines. Netherlands: European Association of Urology. [cited 2023 March 18]. Available from: https://uroweb.org/guidelines/urolithiasis
MANAGEMENT
 Management of Urolithiasis
1. Pain/ Colic
1. “Urological Emergency” 2. Acute kidney injury
3. Urinary retention
4. Sepsis
2. Non Emergency / Outpatients
PAIN/ COLIC RENAL

• NSAID are very effective (Metamizole)

Alternatively : Paracetamol, Diclofenac, ibuprofen

• Second line; offer opiates

• Stone removal/drainage in case of analgesic refractory colic

pain

EAU Guideline 2021

Management of AKI, Urinary retention, sepsis

“Obstructed Kidney”
• Decompression
• Placement of an indwelling ureteral stent
• Percutaneous placement of a nefrostomy tube
• Stone removal should be delayed until the infection is
cleared
• Urine dan blood culture in obstructed kidney with UTI
• Start antibiotic If necessary only and re evaluate
following culture finding
EAU Guideline 2020
Management of AKI, Urinary retention, sepsis
“Obstructed Kidney”

NEPHROSTOMY
 Management of Urolithiasis
1. Pain/ Colic
1. “Urological Emergency” 2. Acute kidney injury (anuria, Olig
3. Urinary retention
4. Sepsis
2. Non Emergency / Outpatients
 MANAGEMENT
MEDICAL Treatment NON MEDICAL
• Medical Expulsive Therapy Treatment
• Chemolysis
• Non-Invasive
• Minimal invasive
• Open Surgery

Urolithiasis Guidelines. Netherlands: European Association of Urology. [cited 2023 March 18]. Available from: https://uroweb.org/guidelines/urolithiasis
MEDICAL EXPULSIVE THERAPY

• Medical expulsive therapy should only be used in informed

patients

• Alpha-blockers for treating > 5mm ureteral stone

• Less effective; Nifedipin, PDE5i, Corticosteroid

• Stone removal/drainage if complications develop (infection,

refractory pain, deterioration of renal function)

EAU Guideline 2021

CHEMOLYSIS
• Percutaneous irrigation chemolysis : option for infection stone
• Oral chemolysis : for uric acid stone, but not sodium or
ammonium urate stones
• Chemolysis is more effective at a higher pH (7.0-7.2)

Dikutip dari EAU Guideline 2020

Extracorporeal shock wave lithotripsy (ESWL)
Extracorporeal shock wave lithotripsy (ESWL)

• Outcome ESWL depends on:

• Size, location and stone composition
• Patients habitus
• Performance of ESWL
• Careful imaging control of location
Specific stone management of ureteral stones

Indications for active removal of stones are ??

Ø Stones with a low likelihood of spontaneous passage

Ø Persistent pain despite adequate analgesic medication
Ø Persistent obstruction
Ø Renal insufficiency (renal failure, bilateral obstruction, or
single kidney)
Ø Infection
Ø Patient preference, comorbidity, social
Dikutip dari EAU Guideline 2020
Ureterorenoscopy (URS) (retrograde and antegrade, RIRS))
Procedure recommendation for staghorn calculi!
 Urolithiasis management review (general recommendation)
Ø Drainage should be performed before starting stone removal in
patient with significant infection & obstruction

Ø The majority of ureteral stones less than 5 mm will pass

spontaneously
Ø Renal stones less than 1 cm are best treated with SWL
Ø Stones between 1 and 2 cm that are not in the lower pole are best
treated with SWL or PNL
Ø Stones greater than 2 cm are best treated with PNL.

Dikutip dari EAU Guideline 2020

PREVENTION
HIGHLIGHT
q HOW TO PREVENT STONE RECCURENT ?
• DIET
• MEDICAL
HEREDITARY ? ?

J UROL, JUNE, 2006

DIAGNOSIS AND EVALUATION

1. HISTORY
2. RFT, URIC ACID, URINALISIS AND KULTUR URINE
3. METABOLIC EVALUATION
4. STONE ANALYSIS
5. APPROPRIATE IMAGING

LOW RISK VS HIGH RISK ??

EAU Guideline 2021
Urine metabolic abnormalities
Measurement The normal value for adult

Urine volume >1.5 liter/day

● A 24-hour urine collection test pH 5.8-6.2

?
Calcium <300mg/day(men), <250mg/day(women)
- HYPERCALCIURIA
- HYPEROXALURIA
Oxalate 30-50mg/day
- HYPOCITRATURIA
- HYPOMAGNESIURIA Uric acid <800mg/day(men), <750mg/day(women)

- DLL
Cystine <75mg/day

Citrate >450mg/day(men), >550mg/day(women)

Phosphate 500-1500mg/day

Sodium 50-150mmol/day

Potassium 20-100mmol/day

Magnesium 50-150mg/day

55 Ammonium 15-60nmol/day
GENERAL DIET RECOMMENDATION

Conservative treatment plan

• High fluid intake (urine output 2 L/day)
• Dietary citrate (4oz concentrated lemon/lime)
• Dietary sodium restriction (<3-5g/day)
• Adequate calcium intake (1200 mg daily)
• Limit animal protein
• Normal BMI and adequate physical activity

EAU Guideline 2021

Fluids Target – 2L of urine
5-year follow-up
Citrate Effect on Lithogenesis
Supersaturation Binds ionic Ca
Citrate
Nucleation and growth Inhibits spontaneous and
Citrate Heterogeneous Nucleation

Growth and aggregation

Retards agglomeration of
Citrate
Preformed CaOx crystals and inhibits
Membrane molecules exposed crystal growth of CaP

Crystal-cell binding
Modified:
Renal stone courtesy of Kris Penniston PhD
 IMPACT OF FRUITS & VEGGIES
Elimination of F&V Addition of F&V
Normal Subjects Stone Formers
Urinary K -62% +68%
Urinary Mg -26% +23%
Urinary Cit -44% +68%
Urinary Ca +49% +10%
Saturation CaOx +30% -52%
Courtesy Dr Glenn Preninger, AUA Review Course Content, 2015 Borghi, et al, 2005
 Limit Calcium

• Low dietary calcium increases risk

of symptomatic kidney stones

NEJM 328: 833-8, 1993

Ann Int Med 126: 553-5, 1997
NEJM 346: 77-84, 2002
 Salt
SODIUM RESTRICTION
• Should not exceed 3-5 g/d

• Excess sodium can cause:

• Increase calcium excretion
• Decrease urinary citrat
• Increased risk of sodium urate crystal

EAU Guideline 2021

 EFFECT OF LOW SALT DIET ON IDIOPATHIC
HYPERCALCIRIA
Nouvenne, Borghi et al, Am J Clin Nutr, 91:565, 2010

URINARY SODIUM URINARY CALCIUM

BASELINE 3 MO.

62% normalized urinary calcium with sodium restriction

 Hypercalciuria

• Sodium restriction
• Thiazid
• K-citrat
 Thiazides
• Decrease urinary CA 20-30%
− Distal Renal Tubule
− Inhibit NA reabsorption, increase CA reabsorption
• Increase Bone Mineral Density
 AHRQ project

Thiazides and stone recurrence

N=565
Mean Duration 34 months Annals of Internal Medicine 158: 535-543, 2013
OXALATE RESTRICTION ?

Foods Item 1 Serving Oxalate Content (mg)

Oxalate-rich Spinach, Cooked ½ cup 755

Foods Rhubarb ½ cup 541
Almonds 1 oz 122
Beets ½ cup 76
 Vitamin B-6
• oxalate excretion with B-6 deficient diet
• stone risk with B-6 intake
• C0-factor in AGT conversion of glyoxylate to
glycine
 Vit B6 and Hyperoxaluria
10
70
60 8
50 6
40
4
30
20 2
10
0
0 Calcium Oxalate Supersaturation
Oxalate (mg/day)
Pre-intervention Post-interventiom
Pre-intervention (SD 30.25 Post-interventiom (SD 14.1)

P<0.0001 57 pts P<0.001

15 month follow-up
72% of pts responded
URIC ACID STONE

• End product purine (Animal protein)

• PH urine < 5,5

Ø Recommendation : 0.8-1.0
grams/kilogram
HIGH ANIMAL PROTEIN DIET

• Increase urinary calcium, uric acid

• Decrease citrate and urinary pH
• Increase bone resorption due to increase
acid-ash content

Br j Urol 56 : 263, 1984

Am j Kid Dis 40 : 265, 2002
CHEMISTRY OF URIC ACID

From Maalouf et al Curr opin Nephrol Hypertens, 2004

BODY WEIGHT AND URINARY PH

Sextile of Weight
IMPACT OF OBESITY
% PREVALENCE OF URIC ACID STONES

Obese Patients Control Group

63%
70%
60%
50%
40%
30%
11%
20%
10%
0%

Courstesy Dr. Glen Preminger, AUA Review Course Content, 2015 Ekerou, et al, 2004
 Allopurinol
Allopurinol if:

• Fails to correct with dietary measures

• Urinary uric acid >900 mg/day
• Start at 100mg and titrate to 300mg if needed
 EXERCISE AND STONES
• National Health and Nutrition Examination Survey database from 2010-2011
‘Have You ever had a kidney stone.’ 8.3% YES

Q1: modetate intensity sports for at least 10 minutes continuously?

RR 0.739

Q2: vigorous intensity sports for at least 10 minutes continuously

RR 0.842

Q3: For the usual way you travel do you walk / bicycle for at least 10 minutes
RR 0.854

Q4: Does your work involve vigorous-intensity activity for at least 10 minutes contuously.
RR 1.334
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