SURGERY DEPARTEMENT Long Case

RSUD W. Z. JOHANNES 20 Mei 2024

FACULTY OF MEDICINE AND VETERINARY MEDICINE
NUSA CENDANA UNIVERSITY

Nefrolithiasis
Presented By:
Ryan Arnold Ethelbert
(2308020014)
Consultant:
dr. Made P. Tambunan, Sp.U

PRESENTED IN THE FRAMEWORK OF CLINICAL CLERKSHIP DUTIES SURGERY DEPARTEMENT

FACULTY OF MEDICINE AND VETERINARY MEDICINE
NUSA CENDANA UNIVERSITY
RSUD PROF. DR. W.Z. JOHANNES
2024
INTRODUCTION
INTRODUCTION
• Urinary tract stones can be classified
into kidney stones, ureteral stones,
and bladder stones, depending on
their location
• Most kidney stones are calcium stones
The exact cause that causes
Management includes
the formation of kidney stones
conservative therapy and
is still unknown, because it
invasive theraphy
involves various factors
 CASE REPORT

Name : Ms. Agnes Ora Manek

PATIENT Sex : Female
IDENTITY Age : 40 years old
Date of admission : 30th April 2024
Room : Asoka
 CASE REPORT
CHIEF COMPLAIN :
Anamnesis
Pain in the right flank

Current Medical • The patient came with complaints of right low back pain.
The pain felt by the patient disappears arising and like
History kneading. Pain was felt since a few months ago. Pain
when urinating (-), fever (-), nausea (-), vomiting (-) The
patient had kidney stone removal surgery in February
2024. After surgery, the patient's low back pain
improved. Patients planned to remove the DJ stent and
clean the remaining stones in March, but were delayed
until May 2024
 CASE REPORT
PAST MEDICAL
DM (-), HT (-), As. urat (-), kolesterol (-)
HISTORY
FAMILY HISTORY (-)
OF ILLNESS
ALLERGY (-)
HISTORY
 CASE REPORT

TREATMENT The patient has undergone kidney stone

HISTORY removal surgery on February 23, 2024

SOCIAL
The patient's job is an elementary school
ECONOMIC teacher
HISTORY
 CASE REPORT
PHYSICAL General status
General condition: Looks moderately
EXAMINATION sick
GCS: E4M5V6
BP : 160/100 mmHg
HR : 52 x/m
RR : 20 x/m
T : 36.4 °C
SpO2 : 100% RA
 CASE REPORT
Secondary Survey
PHYSICAL • Head : Normocephal
EXAMINATION • Eyes : Anemic conjunctive (-/-), icteric sclera (-/-)
• Skin : Pale (-), ichteric (-)
• Neck : Enlarged lymph nodes (-), deformity (-)
• Thorax : Symmetrical chest wall expansion, retraction (-)
• Pulmo : Vesiculer (+/+), rhonchi (-), wheezing (-)
• Cor : S1S2 regular, murmur (-), gallop (-)
• Abdomen : Flat, distension (-), bowel sound (+), tenderness
(-), tympani, CVA (-)
• Upper Extremity : Warm acral, CRT <2 sec, edema (-/-)
• Lower Extremity : Warm acral, CRT <2 sec, edema (-/-)
 CASE REPORT
PHYSICAL Urology status :
• Flank : Bulging (-/-), mass (-/-), hematoma
EXAMINATION (-/-), scar (-/-), tenderness (-/-), CVA (-/-)
• Suprasimphysis : bulging (-), distension (-),
mass (-), hematoma (-), scar (-), tenderness
(-)
• Eksternal genitalia : bulging (-), mass (-),
hematoma (-), scar (-)
 CASE REPORT
Lab Result Unit Reference
LABORATORY Hb 12.7 g/dL 10.8 – 15.6
RESULTS RBC 4.57 10^6/uL 3.80 – 5.80
Hematocrit 35.6 % 33.0 – 45.0
02/05/2024 MCV 77.9 fL 69.0 – 93.0
MCH 27.8 pg 22.0 – 34.0
MCHC 35.7 g/L 32.0 – 36.0
Leucocyte 8.39 10^3/uL 4.50 – 13.50
PLT 339.00 10^3/uL 150 – 400
Na 146 mmol/L 132 – 147
K 3.35 mmol/L 3.50 – 4.50
 CASE REPORT
Lab Result Unit Reference
LABORATORY Cl 107 mmol/L 96 – 111
RESULTS Ca 1.37 mmol/L 1.12 – 1.32
Tot. Ca 2.75 mmol/L 2.20 – 2.55
02/05/2024
 CASE REPORT
• Right kidney: normal size, multiple calcifications
on the medullary wall, no pelvicalyceal ectasis,
RADIOLOGY no cyst/mass, inferior calyx stone +/- 1.3x1.5 cm
(1527 HU), DJ stent (+)
• Right ureter: no visible stone
• Left kidney: normal size, normal parenchym
CT-Scan Urology
density, no pelviocalyceal ectasis visible, no
cyst/mass, inferior calyx stone +/- 0.8x1 cm
(1156 HU)
• Left ureter: no visible stone
• Buli: filled with urine, no visible thickening of
the walls of the jar, no visible stone/mass
 CASE REPORT
Nefrolithiasis dextra
DIAGNOSE DJ stent dextra

PLANNING • Pro RIRS dextra with C-Arm

• IVFD NaCl 0,9% 500 ml / 8 hours
• Cefazolin 1 gr IV
OPERATION
CASE REPORT

C-Arm Pre OP Durante OP C-Arm Post OP

 CASE REPORT
POST – OP
REPORT
• Operator: dr. Made P. Tambunan, Sp.U
• Anesthesiologist: dr. Harry, Sp.An
• Pre Op diagnose: Nefrolithiasis dextra
• Post Op diagnose: Nefrolithiasis dextra
• Operation procedure: Retrograde
Intrarenal Surgery (RIRS) dextra with
laser and C-Arm guiding
• Surgery description:
- The patient in litotomy position with general
anestesy
- Found inferior calix kidney stone, total 1 piece, size
according CT-Scan, mass (-)
- RIRS performed with laser and C-Arm guiding
- Stone broken into flakes of dust
- Minimal bleeding and laseration
- Install 6 Fr stent
- Install 18 fr FC
- Prosedure completed
 Follow May 2, 2024 – Morning
S / Pain in the genital are post op Head : Normocephal
Eyes : Anemic conjunctive (-/-), icteric sclera (-/-)
Skin : Pale (-), ichteric (-)
O/ General Status :
Neck : Enlarged lymph nodes (-), deformity (-)
TD: 110/70 mmHg, Thorax : Symmetrical chest wall expansion,
T : 36.4°, retraction (-)
HR : 82x/m
RR : 20x/m, Pulmo : Vesiculer (+/+), rhonchi (-), wheezing (-)
SpO2 :99% RA Cor : S1S2 regular, murmur (-), gallop (-)
Abdomen : Flat, distension (-), bowel sound (+),
A/ Post RIRS (D) + DJ Stent (D) tenderness (-), tympani, CVA (-)
P/ Urologist
IVFD NaCl 0,9% 500ml : Upper Extremity : Warm acral, CRT <2 sec, edema
Futrolit 500 ml, 2 : 1 /24 (-/-)
jam
Inj Ceftriaxon 1x2 gr IV Lower Extremity : Warm acral, CRT <2 sec, edema
Levofloxacin 1x500 mg (-/-)
PO
Inj Antrain 3x1 gr IV
Ranitidin 3x50 mg PO
Vit. K 3x1 mg PO
PCT 3x1000mg IV
 Follow May 3, 2024 – Morning
S / Fever (-), vomiting (-), nausea (-), flank pain (+) Head : Normocephal
Eyes : Anemic conjunctive (-/-), icteric sclera (-/-)
Skin : Pale (-), ichteric (-)
O/ General Status :
Neck : Enlarged lymph nodes (-), deformity (-)
TD: 120/80 mmHg, Thorax : Symmetrical chest wall expansion,
T : 36.7°, retraction (-)
HR : 90x/m
RR : 20x/m, Pulmo : Vesiculer (+/+), rhonchi (-), wheezing (-)
SpO2 : 99% RA Cor : S1S2 regular, murmur (-), gallop (-)
Abdomen : Flat, distension (-), bowel sound (+),
A/ Post RIRS (D) + DJ Stent (D) tenderness (-), tympani, CVA (-)
P/ Urologist
Minum air 1L/hari Upper Extremity : Warm acral, CRT <2 sec, edema
IVFD NaCl 0,9% 500ml : (-/-)
Futrolit 500 ml, 2 : 1 /24 jam Lower Extremity : Warm acral, CRT <2 sec, edema
Inj Ceftriaxon 1x2 gr IV (-/-)
Levofloxacin 1x500 mg PO
Inj Antrain 3x1 gr IV
Omeprazole 2x40 mg PO
Sucralfat syrup 3x1C PO
KSR 2x1 PO
Ondansentron 2x4mg IV
LITERATURE
REVIEW
 LITERATURE
ANATOMY REVIEW
 LITERATURE
ANATOMY REVIEW
 LITERATURE
PHYSIOLOGY REVIEW

Maintains acid and

Maintains body fluid
Excretes of toxins alkaline level of body
balance
fluid

Excretes final metabolic

remnants of ureal Production of
Activates Vitamin D
protein, creatinine and hormones
ammonia
 LITERATURE
DEFINITION REVIEW

Nefrolithiasis:
A condition in which there are one
or more stones in the pelvis or calix
of the kidneys
 LITERATURE
EPIDEMIOLOGY REVIEW

Yearly prevalence:
Affect all geographical regions
3-5% around the world
The most frequent
Lifetime urology case in Indonesia
prevalence: 15-25%

Peak incidence occurring Males are more common

at 40-50 years of age than females at 3:1
 LITERATURE
ETIOLOGY REVIEW

Intrinsic Factors
Have a family
20 – 50 years
Male history of
old
kidney stones

Kidney or
Comorbid
urinary tract
disease
abnormalities
 LITERATURE
ETIOLOGY REVIEW

Extrinsic Factors

Workplace Low drinking

Foods
and residence intake

Sedentary Certain
lifestyle medication
 LITERATURE
PATHOPHYSIOLOGY REVIEW
Supersaturation Theory
• The degree of saturation of the components forming kidney
stones favors crystallization. Crystals that accumulate cause
crystal aggression and then arise into stone

Matrix Theory
• The matrix is a mucoprotein consisting of 65% protein, 10%
hexose, 3-5 hexosamine and 10% water. The matrix causes the
attachment of the crystals so that they become stones
 LITERATURE
MANIFESTATION REVIEW
Low Back
Hematuria Pain
Piuria Renal
colic
Frequency Pain in the
lumbar region
Urgency Anorexia, vomiting
and flatulence
 LITERATURE
DIAGNOSE REVIEW

Blood chemistry
Chemical
and 24-hour Plain photo/BNO
analysis
urine tests
IVP
USG
Urine culture
 LITERATURE
MANAGEMENT REVIEW
Conservative
• Diuresis 2 liter/day with drinking water
• Alpha-blocker
• NSAID

ESWL

Operative
• URS and RIRS
• PCNL
• Nefrolithotomy
 LITERATURE
PREVENTATION REVIEW

Drink fresh water

Monitor fluid
2,5-3 liter

Do not consume
Consume high fiber more vitamin C than
food the recommended
daily dose
 LITERATURE
COMPLICATION REVIEW

Ureteral
Hydronephrosis
obstruction

Squamous cell
Infection/urosepsis
carcinoma
DISCUSSION
 DISCUSSION
THEORY CASE

- Hematuria In the case of patients experiencing

- Piuria symptoms, namely pain in the lumbar
- Polychisuria/frequency region, pain that disappears sometimes
- Urgency radiates to the hip area, On physical
- Low back pain radiates to the hip area, is examination there is no CVA pain
continuous in the lumbar region.
- Renal colic that occurs suddenly and
disappears slowly.
- Pain in the lumbar region, radiating to the
lower middle abdomen, then towards the penis
or vulva.
- Anorexia, vomiting and flatulence
 DISCUSSION
THEORY CASE

Diagnose test for In the patient, a CT scan was

Nefrolithiasis: carried out and an inferior
1. Blood test, 24 hours calyx stone of the right
urine test kidney was obtained.
2. Urine chemistry
3. Plain X-ray
4. IVP
5. CT-scan
6. USG
 DISCUSSION
THEORY CASE

Therapy In these patients are given

1. Conservative RIRS procedure
2. ESWL
3. Operation procedure
1. URS/RIRS
2. PCNL
3. Nefrolithotomy
 CONCLUSION
A case of nephrolithiasis (kidney stones) has been reported, Mrs.
ADM aged 40 years. This patient is diagnosed based on anamnesis,
physical examination and supporting examinations. The patient will
be treated surgically on May 2, 2024 with RIRS. During treatment in
the hospital, the patient receives treatment according to indications.
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