URINARY TRACT STONE

Dr. H. Suharjendro, SpU

Sub Bagian Urologi Bagian/SMF Ilmu Bedah
Fakultas Kedokteran UI / RSCM
Jakarta
URINARY STONE DISEASE
 BACKGROUND
 Greec : Mumi 7000 B.C.
 Development country :
CARDINAL FEATURES

 Colicky flank pain of sudden onset

 Decrease pain with a change in position
 Hematuria
 Dysuria, urinary frequency and/or urgency
 Nausea, vomiting
 Pain migrating from the flank to the ipsilateral: groin and
testicle (in male)/labia (in female)
 Passage of stone or gravel in the urine (common in uric acid
stone)
EPIDEMIIOLOGY
 Demographics
 Genetics
 Polygenic defect with partial penetrance
 Influence of diet
 Geography
 Increase incidence found in :
 Desert
 Tropical regions
 Mountainous
 Suggesting dehydration and decreased fluid intake
EPIDEMIIOLOGY

 Incidence : 0,7-2,1 per 1000

 Prevalence : 30% of population has kidney stone
 Approx.50% of this pop. will experience symptoms
from their stone disease
 Frequency : 10% of the pop. (US) will suffer
nephrolithiasis at some time in their lives
EPIDEMIIOLOGY
 Demographics
 Age : Peak incidence between 20-40 years of age

 Gender : Male : Female ratio is 3 : 1

 Race :
 Increased incidence in whites and Asians
 Decreased incidence in native Americans, Africans and

 Africans-Americans, native born Israelis and other

PREDISPOSING FACTORS

 Decreased fluid intake

 Increased fluid loss (in hot, dry climates)
 Dehydration
 Coffee, tea and wine (lower rate stone
formation)
 Diet rich in meat, tomatoes, grape juice,
sodium and oxalate (higher risk of stone
formation)
 Male sex and white race
SYNONIMS

 Nephrolithiasis
 Urolithiasis
 Urinary lithiasis
 Ureterolithiasis
 Urinary or renal calculi
 Staghorn calculus
 Kidney or urinary stone
 Renal colic
DIAGNOSE
1. Symptoms and signs
2. Physical examination
3. Laboratory examination
4. Radiology examination
5. Stone analysis
 Symptoms
1. Severe, colicky flank pain; colic lasting
from 20-60min may include radiation of
pain into the groin, labia, penis, testicles,
thigh
2. Hematuria (gross or microscopic)
3. Nausea, vomiting, diarrhea
4. Dysuria, urinary frequency and/or
urgency
 Presentation and Differential
Diagnosis
Relationship of Stone Location to Symptoms
Stone location Common symptoms
Kidney Vague flank pain, hematuria

Proximal ureter Renal colic, flank pain, upper

abdominal pain

Middle section of ureter Renal colic, anterior abdominal pain,

flank pain

Distal ureter Renal colic, dysuria, urinary

frequency, anterior abdominal pain,
flank pain
 Signs
1. A restless, writhing patient unable to decrease
pain by changing position
2. Frequent flank/costovertebral angle
tenderness demonstrated
3. May be tachycardic or bradycardic
4. May be hypertensive
5. Benign abdominal examination
6. May note hypoactive bowel sounds, indicative
of associated ileus
 Fever and chills, indicative of concomitant
infection
 Symptoms that may be referable to a more
serious, potentially lethal condition, including
abdominal aneurysm; bowel obstruction;
appendicitis
 CONSIDER CONSULT

1. Patients with fever or chills suggestive of

obstruction or pyelonephritis
2. Septic patients
3. Patients with intractable pain
4. Patients with ureteral obstruction
5. Patients in acute renal failure
6. Patients with hydronephrosis
Physical examination
 General Examanation : T, N, R, t
 Lokal Examanation :
 Flank : CVA ; mass, etc.
 Suprapubic
 DRE
Laboratory examination
 General

 Specific : Renal function

Urinalysis

 Stone analysis
Stone Analysis
 Calcium stones
 Hypercalcuria
 Hyperoxaluria
 Cystine
 Struvite
 Uric acid
 Xanthine
 Dyhydroxyadeninuria (DHA)
 Crixivan
Radiology examination

 BOF/KUB
 USG
 BNO-IVP
 CT Scan
 RPG ( Retrograd Pyelography )
BOF/KUB
MANAGEMENT GOALS
 Relieve pain
 Ensure that any complications,
including infection and
obstruction, are identified and
treated
 Reduce the risk of recurrence
Conservative Management
Indication
 No obstruction
 Diameter < ½ cm
 No sepsis
Treatment recommended
 Analgesia
 Spasmolitic
Referral to hospital
Referral to hospital
 for release pain
 for definitive stone treatment
Treatment recommended
 Lithotripsy
 URS
 PNL/PCN
 SWL
 Open surgery
Depend on Size, Location, Number of stone, and
(Hospital degree).
 Treatment recommended

Depend on Size, Location, Number of stone,

and (Hospital degree).

1. SWL
2. URS
3. PNL/PCNL
4. Lithotripsy
5. Open surgery
Extracorporeal shockwave lithotripsy
( ESWL )
Extracorporeal shockwave
lithotripsy (ESWL)
 Efficacy
Efficacious as a sole therapy for about 70% of stones.
 Risks:
 May require multiple primary treatments for adequate
fragmentation
 May require ancillary treatment
 Contraindicated i: Pregnant patients, patients with certain
bleeding tendencies, very obese patients (>300 lb, 136kg),
impacted stones, cystine stones, distal ureteral obstruction
 Benefits:
 Minimally invasive
 Can often be performed without anesthesia or with
intravenous sedation
Extracorporeal shockwave
lithotripsy (ESWL)
 Evidence
 ESWL is recommended as a first-line therapy for most
patients with stones 1cm or less in the proximal ureter
[1] Level C
 ESWL is an acceptable treatment option for patients
with stones greater than 1cm in the proximal ureter [1]
Level C
 ESWL is effective for the management of distal urethral
stones [1] Level C
 Acceptability to patient
 High patient satisfaction; minimally invasive with few
side-effects.
Extracorporeal shockwave
lithotripsy (ESWL)
 Follow up plan
 Must follow-up to ensure that stone fragments have
been passed and that no obstruction has supervened.
 Patient and caregiver information
 Patient may note blood in the urine for several days
following ESWL and bruising or tenderness of the back
and/or abdomen
 Fragmented bits of calculi may continue to cause pain
as they pass
 A ureteral stent may be required to drain the kidney past
inflammation
 The patient should be aware of signs of infection
 Percutaneous
Nephrolithotomy
( PNL = PCNL = PCN )
Percutaneous nephrolithotomy (PNL)
 Risk:
 Requires anesthesia, heavy sedation
 Benefits:
 Removes stone fragments rather than awaiting
passage
 Safest procedure when intervention is required in a
pregnant patient
 Can remove stones that are greater than 2cm diameter
that are not amenable to ESWL
 Can remove stones of different chemical composition,

e.g. cystine, calcium oxalate

Percutaneous nephrolithotomy (PNL)
 Evidence
 Percutaneous nephrolithotomy is an acceptable
alternative option to ESWL (when ESWL is
inappropriate or fails) in patients with stones less than
or equal to 1cm in the proximal ureter [1] Level C
 Percutaneous nephrolithotomy is also an acceptable
treatment option for patients with stones greater than
1cm in the proximal ureter [1] Level C
 Acceptability to patient
 May require placement of a nephrostomy tube.
Percutaneous nephrolithotomy (PNL)
 Follow up plan
 This is an invasive procedure that will require
hospitalization in the immediate postoperative
period.
 Patient and caregiver information
 Education regarding nephrostomy tube
 Education about how to self-monitor for
development of infection
 URS :
Uretero-Renoscopy
Ureteroscopy (URS)
 Efficacy
 A higher success rate than ESWL. Particularly
efficacious for stones impacted below the iliac crest.
 Risks:
 Requires anesthesia or heavy sedation
 A stent may need to be placed for up to a week
postoperatively
 Benefits:
 Good success rate
 Low risk of multiple or ancillary treatments being

needed
Ureteroscopy (URS)
 Evidence
Uteroscopy is an acceptable treatment option for patients
with stones >1cm in the proximal ureter. Uteroscopy may be
less appropriate for larger stones [1] Level C
 Uteroscopy is an acceptable alternative option to ESWL
(when ESWL is inappropriate or fails) in patients with stones
less than or equal to 1cm in the proximal ureter [1] Level C
 Uteroscopy is an effective treatment option for distal ureteric
stones [1] Level C
 Acceptability to patient
 May require general anesthesia, which carries its own risks.
Lithotripsy
Lithotrypsi
 Lithotrypsi on Bladder Stone
( Vesico-litholapaxy )

 Aligator
 Hendrickson
 Open Surgery
1. Kidney Stone :
1. Pyelolithotomy
2. Extended Pyelolithotomy
3. Nephrolithotomy
4. Bivale Nephrolithotomy / Longitudinal
Nephrolithotomy ( Kadet )

2. Ureterolithiasis ( Ureter Stone ) :

Ureterolithotomy
3. Vesicolithiasis ( Bladder Stone ) :
Vesicolithotomy / Sectio Alta
 Open Surgery

1. Kidney Stone :
1. Pyelolithotomy
2. Extended Pyelolithotomy
3. Nephrolithotomy
4. Bivale Nephrolithotomy / Longitudinal
Nephrolithotomy ( Kadet )
Ureterolithiasis ( Ureter Stone ) :

Ureterolithotomy
Vesicolithiasis ( Bladder Stone ) :

Vesicolithotomy / Sectio Alta