URETHEROLITHIASIS

DIAGNOSIS, MANAJEMEN, KOMPLIKASI, PROGNOSIS

DIAGNOSIS
• medical history and physical examination.
• Patients with ureteral stones usually present with :
loin pain, nausea, vomiting, and sometimes fever, but may also
be asymptomatic
• Riwayat nyeri flank
• Nyeri colic
DIAGNOSIS
Riwayat faktor risiko :
• Crystalluria : Crystalluria is a risk factor for stones. Stone formers, especially
those with calcium oxalate stones, frequently excrete more calcium oxalate
crystals, and those crystals are larger than normal (>12 μm).
• Sosioekonomik
• Diet
• Occupation
• Climate
• Family history
• Medications
 DIAGNOSIS
• The antihypertensive medication triamterene is found as a component of
several medications, including Dyazide, and has been associated with
urinary calculi with increasing frequency.
• Long-term use of antacids containing silica has been associated with the
development of silicate stones.
• Carbonic anhydrase inhibitors may be associated with urinary stone
disease (10–20% incidence).
• The long-term effect of sodium- and calcium-containing medications on
the development of renal calculi is not known.
• Protease inhibitors in immunocompromised patients are associated with
radiolucent calculi.
 DIAGNOSIS
PHYSICAL EXAMINATION
• acute renal colic typically is in severe pain, often attempting to find relief in
multiple, frequently bizarre, positions. (helps differentiate patients with this
condition from those with peritonitis, afraid to move)
• Systemic components of renal colic : tachycardia, sweating, and nausea
often prominent.
• Costovertebral angle tenderness may be apparent. An abdominal mass may
be palpable in patients with long-standing obstructive urinary calculi and
severe hydronephrosis.
• A rectal examination helps exclude other pathologic conditions.
 DIAGNOSIS
RADIOLOGIC EXAM
1. CT- SCAN (NCCT)
• Noncontrast spiral CT scans are now the imaging modality of choice in patients presenting with
acute renal colic. It is rapid and is now less expensive than an intravenous pyelogram (IVP).
• It images other peritoneal and retroperitoneal structures and helps when the diagnosis is
uncertain.
• Uric acid stones are visualized no differently from calcium oxalate stones. Matrix calculi have
adequate amounts of calcium to be visualized easily by CT scan. HU can help predict stone type
and hardness.
• The increased use of CT scans has also increased the radiation exposure to stone patients,
especially those with recurrent disease. CT scans should be used when the diagnosis is in doubt
and should not be routinely utilized for diagnosis or surveillance
 DIAGNOSIS
RADIOLOGIC EXAMINATION
2. INTRAVENOUS PYELOGRAPH
• can simultaneously document nephrolithiasis and upper-tract anatomy
• rarely used today
• Oblique views easily differentiate gallstones from right renal calculi.
3. TOMOGRAPHY
4. KUB films and directed ultrasonography
• The distal ureter is easily visualized through the acoustic window of a full bladder.
Edema and small calculi missed on an IVP can be appreciated with such studies.
5. Retrograde pyelography
localize small or radiolucent offending calculi
 DIAGNOSIS
RADIOLOGIC EXAMINATION
2. INTRAVENOUS PYELOGRAPH
• can simultaneously document nephrolithiasis and upper-tract anatomy
• rarely used today
• Oblique views easily differentiate gallstones from right renal calculi.
3. TOMOGRAPHY
4. KUB films and directed ultrasonography
• The distal ureter is easily visualized through the acoustic window of a full bladder.
Edema and small calculi missed on an IVP can be appreciated with such studies.
5. Retrograde pyelography
localize small or radiolucent offending calculi
Manajemen
1. Conservative Observation

Mayoritas batu ureter dapat keluar secara spontan, tergantung ukuran. Ukuran batu 4-5mm sekitar 40-50% dapat keluar spontan, sedangkan
>6mm lebih dari 15% dapat keluar spontan. Spontaneous passage dapat dibantu oleh MET (Medical Expulsive Therapy) seperti alpha blocker,
NSAID, dan low dose steroid. Semakin distal letak batu, semakin mungkin keluar spontan (sekitar 6minggu dari onset).

2. Dissolution agent
- Contoh obat alkalinizing agent:
- Oral: Na/K HCO3, potassium citrate
- Intrarenal (percutaneous nephrostomy tube, retrograde catheter): NaHCO3, Tromethamin-E (untuk uric acid dan cystine calculi)
- Prinsip: mengatur pH urin agar dapat menghancurkan batu

3. Relief of Obstruction
• Indikasi: untuk pasien dengan ureterl calculi (obstruksi) disertai demam dan tanda-tanda infected urin sehingga membutuhkan emergency
drainase.
• Prosedur: retrograde pyelography (memberikan kontras x-ray) kemudian dilakukan retrograde placement of double-J stent.
Manajemen
1. Conservative Observation

Mayoritas batu ureter dapat keluar secara spontan, tergantung ukuran. Ukuran batu 4-5mm sekitar 40-50% dapat keluar spontan,
sedangkan >6mm lebih dari 15% dapat keluar spontan. Spontaneous passage dapat dibantu oleh MET (Medical Expulsive Therapy)
seperti alpha blocker, NSAID, dan low dose steroid. Semakin distal letak batu, semakin mungkin keluar spontan (sekitar 6minggu dari
onset).

2. Dissolution agent
- Contoh obat alkalinizing agent:
- Oral: Na/K HCO3, potassium citrate
- Intrarenal (percutaneous nephrostomy tube, retrograde catheter): NaHCO3, Tromethamin-E (untuk uric acid dan cystine calculi)
- Prinsip: mengatur pH urin agar dapat menghancurkan batu

3. Relief of Obstruction
• Indikasi: untuk pasien dengan ureterl calculi (obstruksi) disertai demam dan tanda-tanda infected urin sehingga membutuhkan
emergency drainase.
• Prosedur: retrograde pyelography (memberikan kontras x-ray) kemudian dilakukan retrograde placement of double-J stent.
Manajemen
Pencegahan (Manajemen Prophylaxis)
Untuk mencegah kejadian ureteral calculi yang berulang
1. Gaya hidup:
- menghindari faktor resiko
- motivasi dan edukasi pasien
- meminum air 1,5-2L/hari

2. Evaluasi metabolic
- Urin Collection dalam 24jam setalah dilakukan pengambilan batu, ukur kadar:
calium, oxalate, phosphate, uric acid, dll, voulme, pH
- Pastikan serum level dalam batas normal: BUN, creatinin, uric acid, calcium,
phosphat
Manajemen
3. Oral Medication
- Alkalinizing pH agent: potassium citrate : Indikasi: untuk calcium oxalate calculi
secondary to hypocitraturia
- GI absorption inhibitor: celullose phosphate : Untuk ikat Ca di usus + cegah Ca
diabsorpsi dan disekresi di urin Indikasi: untuk pasien type 1 absorptive hypercalciuria
- Phosphate supplementation : Untuk mengatasi renal phosphate leak
- Diuretik: Thiazid : Untuk perbaiki renal calcium leak terkait hypercalciuria. Efek:
menekan ekskresi Ca lewat urin
- Calcium Suplementation Indikasi: untuk hyperoxaluric calcium nephrolithiasis
- Uric acid lowering medication: Allopurinol. Indikasi: untuk hyperuricosuric calcium
nephrolithiasis (mixed calcium oxalate & uric acid)
- Urease inhibitor: Acetohydroxomic Acid. Indikasi: unutk chronic urea-splitting UTI terkait
struvite stone dengan cara cegah bakterial urease, mengasamkan urin.
- Prevention of cystein calculi: Penicillamin, Thiol. Efek: mengikat sulfide pada cystine
sehingga lebih larut air
 Extracorporal Shockwave Lithotripsy (ESWL)
- Suatu teknik menghancurkan batu dengan - Memasukan alat ureteroscopy per-
menggunakan gelombang kejut
bertekanan tinggi yang akan melepaskan
energi ketika melewati area-area yang
mempunyai kepadatan akustik berbeda
sehingga batu menjadi hancur menjadi
partikel-pertikel kecil
- Posisi pasien berbaring di meja dan
lithotriptor didekatkan ke bagian yang
terdapat batu
- Indikasi: batu ukuran 4mm-2cm
- Kontraindikasi: ibu hamil, perdarahan
abdomen, malnutrisi, obesitas
- Komplikasi: infeksi, trauma saluran
kemih, nyeri
Ureterorenoscopy (URS)
uretram dengan memakai energi tertentu, mengambil batu yang berada di ureter
batu yang berada dalam ureter dapat
dipecah/diambil melalui tuntunan
ureteroscopy
- Indikasi: ukuran batu < 1cm
- Perawatan di RS selama 2 hari
- Komplikasi: trauma mukosa saluran
kemih, perdarahan, perforasi ureter, nyeri
Ureterolithotomy (Open surgery)
- Operasi/pembedahan terbuka untuk
- Dilakukan melalui insisi samping, dorsal
atau anterior, tergantung lokasi batu
- Jarang dilakukan, kecuali pada pasien
dengan ukuran batu besar (>2cm),
kelainan anatomi ureter, tindakan minimal
invasive gagal
- Perawatan di RS 2-7 hari
- Komplikasi: infeksi, perdarahan, urinary
fistula, urinoma
Indikasi rawat inap
• Fever.
• Solitary kidney.
• Known non-functioning kidney.
• Inadequate pain relief or persistent pain.
• Inability to take adequate fluids due to nausea and vomiting.
• Anuria.
• Pregnancy.
• Poor social support.
• Inability to arrange urgent outpatient department follow-up.
• People over the age of 60 years should be admitted if there are concerns on clinical
condition or diagnostic certainty (a leaking aortic aneurysm may present with
identical symptoms)
Initial management of acute presentation[

• Non-steroidal anti-inflammatory drugs (NSAIDs), usually in the form of

diclofenac IM or PR, should be offered first-line for the relief of the
severe pain of renal colic.
• NSAIDs are more effective than opioids for this indication and have
less tendency to cause nausea. However, if parenteral morphine is
required in severe renal colic pain, this works quickly and can provide
pain relief in the time taken for an NSAID to work.
Initial management of acute presentation
• Provide antiemetics and rehydration therapy if needed.
• The majority of stones will pass spontaneously but may
take 1-3 weeks; patients who have not passed a stone
or who have continuing symptoms should have the
progress of the stone monitored at a minimum of
weekly intervals to assess the progression of the stone.
 Initial management of acute presentation
• Conservative management may be continued for up to three
weeks unless the patient is unable to manage the pain, or if
he or she develops signs of infection or obstruction.
• Medical expulsive therapy may be used to facilitate the
passage of the stone. It is useful in cases where there is no
obvious reason for immediate surgical removal. Calcium-
channel blockers (eg, nifedipine) or alpha-blockers (eg,
tamsulosin) are given. A corticosteroid such as prednisolone
is occasionally added when an alpha-blocker is used but
should not be given as monotherapy.
 Managing patients at home
• All patients managed at home should drink a lot of fluids
and, if possible, void urine into a container or through a tea
strainer or gauze to catch any identifiable calculus.
• Analgesia: paracetamol is safe and effective for mild-to-
moderate pain; codeine can be added if more pain relief is
required. Paracetamol and codeine should be prescribed
separately so they can be individually titrated.
KOMPLIKASI
• Complete blockage of the urinary flow from a kidney
decreases glomerular filtration rate (GFR) and, if it persists
for more than 48 hours, may cause irreversible renal
damage.
• If ureteric stones cause symptoms after four weeks, there is a
20% risk of complications, including deterioration of renal
function, sepsis and ureteric stricture.
• Infection can be life-threatening.
• Persisting obstruction predisposes to pyelonephritis.
 prognosis
• Most symptomatic renal stones are small (less than 5 mm in diameter)
and pass spontaneously.
• Stones less than 5 mm in diameter pass spontaneously in up to 80% of
people.
• Stones between 5 mm and 10 mm in diameter pass spontaneously in
about 50% of people.
• Stones larger than 1 cm in diameter usually require intervention (urgent
intervention is required if complete obstruction or infection is present).
• Two thirds of stones that pass spontaneously will do so within four weeks
of onset of symptoms.
• A stone that has not passed within 1-2 months is unlikely to pass
spontaneously.
 prognosis
• The following features predispose to recurrent stone formation:
- First attack before 25 years of age.
- Single functioning kidney.
- A disease that predisposes to stone formation.
- Abnormalities of the renal tract.