NEPHROLITHIASIS NEPHROLITHIASIS S S

Urology Division, Surgery DepartmentUrology Division, Surgery Department

Medical Faculty Medical Faculty

University of Sumatera Utara University of Sumatera Utara

PRESENTATIONPRESENTATION

�� Renal colicRenal colic

-- classically : flank pain, often acute inclassically : flank pain, often acute in

onset, radiating to the ipsilateral abdomenonset, radiating to the ipsilateral abdomen

-- distal ureteral stones distal ureteral stones �� ipsilateral groin,ipsilateral groin,-- distal ureteral stones distal ureteral stones �� ipsilateral groin,ipsilateral groin,

testicular (can mimic torsion ortesticular (can mimic torsion or

epididimytis), vulvar painepididimytis), vulvar pain

-- waxes & waneswaxes & wanes

-- frequently move about to find a more frequently move about to find a more

comfortable positioncomfortable position

RENAL COLIC

� Sudden onset, no relief with change of position

� Nause & vomiting

� Diagnosis studies :Diagnosis studies :

- urinalysis

- non-contrast CT scan

- plain radiograph

- white count and serum creatinin

- urine culture

- IVP

�� Nausea & vomitingNausea & vomiting

�� Irritative voiding symptomIrritative voiding symptom

�� Hematuria (gross or microscopic)Hematuria (gross or microscopic)�� Hematuria (gross or microscopic)Hematuria (gross or microscopic)

�� Urinary infectionUrinary infection

�� Fever, esp if infection presentFever, esp if infection present

�� Occasionally asymptomatic, with stones Occasionally asymptomatic, with stones

detected incidentallydetected incidentally

PAST MEDICAL HISTORYPAST MEDICAL HISTORY

�� ↓↓ fluid intakefluid intake

�� Urinary tract infectionUrinary tract infection

�� HighHigh--protein diet (associated with acidosis, protein diet (associated with acidosis, hypocitraturia, hypercalciuria, hypocitraturia, hypercalciuria, hypocitraturia, hypercalciuria, hypocitraturia, hypercalciuria, hyperuricosuria, hyperoxalouria)hyperuricosuria, hyperoxalouria)

�� IBD, small bowel resection, jejunoileal IBD, small bowel resection, jejunoileal bypass (hyperoxaluria & Ca oxalate stones)bypass (hyperoxaluria & Ca oxalate stones)

�� Primary hyperparathyroidism Primary hyperparathyroidism (hypercalciuria & Ca oxalate stone)(hypercalciuria & Ca oxalate stone)

�� Gout (uric acid stone)Gout (uric acid stone)

�� Total colectomy (uric acid stone)Total colectomy (uric acid stone)

�� RTA (Ca phosphate stones)RTA (Ca phosphate stones)

�� Medication :Medication :

-- steroids (hypercalciuria)steroids (hypercalciuria)

-- loop diuretics (hypercalciuria)loop diuretics (hypercalciuria)-- loop diuretics (hypercalciuria)loop diuretics (hypercalciuria)

-- colchicine (hyperuricosuria)colchicine (hyperuricosuria)

-- vitamin Dvitamin D

-- antacidsantacids

-- triamterenetriamterene

-- indinavirindinavir

�� Associated GU diseases:Associated GU diseases:

-- UPJ obstruction UPJ obstruction

-- bladder reconstructionbladder reconstruction

-- BPHBPH-- BPHBPH

-- medullary sponge kidney medullary sponge kidney

�� Family history of stonesFamily history of stones

�� Social history :Social history :

-- immobility and sedentary lifestyle immobility and sedentary lifestyle �� ↑↑ riskrisk

-- wine / beer wine / beer �� ↓↓ riskrisk

EVALUATION IN THE ACUTE SETTINGEVALUATION IN THE ACUTE SETTING

�� PHYSICAL EXAMPHYSICAL EXAM

-- evaluate for feverevaluate for fever

�� concomitant infection may beconcomitant infection may be�� concomitant infection may beconcomitant infection may be

associated with tachycardia and/or associated with tachycardia and/or

hypertensionhypertension

-- abdominal exam to evaluate for flankabdominal exam to evaluate for flank

tenderness/peritonitistenderness/peritonitis

URINALYSIS AND URINE CULTUREURINALYSIS AND URINE CULTURE

�� RBC usually present, WBC may be presentRBC usually present, WBC may be present

�� pH : pH : < 5.5 + radioluscent stone < 5.5 + radioluscent stone �� uric acid stoneuric acid stone

> 5.5 + metabolic acidosis, hypokalemia> 5.5 + metabolic acidosis, hypokalemia

& hyper chloremia & hyper chloremia �� RTARTA& hyper chloremia & hyper chloremia �� RTARTA

> 6.0 > 6.0 �� struvitstruvit

�� Crystals :Crystals :

-- Ca oxalate Ca oxalate �� dumbbell/hourglass/bipyramidaldumbbell/hourglass/bipyramidal

-- Ca phosphate Ca phosphate �� needleneedle--shaped/amorphousshaped/amorphous

-- uric acid uric acid �� amprphous/rosettesamprphous/rosettes

-- struvite struvite �� coffin lidcoffin lid

-- cystine cystine �� benzene ring/hexagonalbenzene ring/hexagonal

SERUM STUDIESSERUM STUDIES

�� Complete blood countComplete blood count

�� ElectrolytesElectrolytes

�� CalciumCalcium�� CalciumCalcium

�� PhosphatePhosphate

�� Uric acidUric acid

IMAGINGIMAGING

�� KUBKUB

-- 5 typical location of stone impaction :5 typical location of stone impaction :

calyxcalyxcalyxcalyx

ureteropelvic junction (UPJ)ureteropelvic junction (UPJ)

pelvic brim (iliacs)pelvic brim (iliacs)

posterior pelvis (broad ligament, females)posterior pelvis (broad ligament, females)

ureterovesical junction (UPJ)ureterovesical junction (UPJ)

KUBKUB

�� Intravenous pyelogram (IVP)Intravenous pyelogram (IVP)

-- nowadays, rarely used in the acute settingnowadays, rarely used in the acute setting

�� UltrasoundUltrasound

-- pregnancy & pediatrics : avoids radiationpregnancy & pediatrics : avoids radiation

-- poor visualization of small renal & ureteralpoor visualization of small renal & ureteral

stonesstones

IVPIVP

USG

�� NonNon--contrast computed tomographycontrast computed tomography

-- 97% sensitive & 97% specific for stone97% sensitive & 97% specific for stone

-- 4 signs of obstruction :4 signs of obstruction :-- 4 signs of obstruction :4 signs of obstruction :

hydroureterhydroureter

perinephric strandingperinephric stranding

hydronephrosishydronephrosis

nephromegalynephromegaly

ACUTE MANAGEMENTACUTE MANAGEMENT

�� Pain control : Pain control : -- narcoticsnarcotics

-- NSAIDSNSAIDS

�� IV fluidsIV fluids

�� AB if urinary infection (+)AB if urinary infection (+)

Strain urineStrain urine�� Strain urineStrain urine

�� Recommended indication for admission :Recommended indication for admission :

-- uncontrolled painuncontrolled pain

-- unremitting nausea/vomiting with inability tounremitting nausea/vomiting with inability to

tolerate POtolerate PO

-- obstructed, infected renal unitobstructed, infected renal unit

-- obstructed, solitary renal unitobstructed, solitary renal unit

-- bilateral obstructionbilateral obstruction

-- anuriaanuria

�� Recommended indication for watchful waitingRecommended indication for watchful waiting

-- no evidence of infectionno evidence of infection

-- pain wellpain well--controlled with oral medicationcontrolled with oral medication

-- stone < 5 mmstone < 5 mm-- stone < 5 mmstone < 5 mm

-- no obstructionno obstruction

�� Spontaneous stone passage rates based on Spontaneous stone passage rates based on location :location :

-- proximal : 20%proximal : 20%

-- distal : 70%distal : 70%

�� Spontaneous passage rates within 1 year :Spontaneous passage rates within 1 year :

< 4 mm< 4 mm 90%90%

4 4 –– 6 mm6 mm 60%60%4 4 –– 6 mm6 mm 60%60%

> 6 mm> 6 mm 20%20%

Obstruksi ureter akut

prostaglandin

diuresis

Suspresi hormon anti diuretikVaso dilatasi ginjal

Peningkatan tekanan pelvis renalis

Nyeri meningkat

diuresis

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 MEDICAL OPTIONS DURING

EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT

�� Pain controlPain control

�� AB prophylaxisAB prophylaxis

�� Alpha blockersAlpha blockers�� Alpha blockersAlpha blockers

�� Ca channel blockersCa channel blockers

�� steroidssteroids

SURGERYSURGERY

�� ESWLESWL

-- imaging : fluoroscopyimaging : fluoroscopy

-- anesthesia : sedation or generalanesthesia : sedation or general

-- potential longpotential long--term renal effect :term renal effect :

renal injury/scar, hypertensionrenal injury/scar, hypertension

-- complications :complications :

hematoma (<1%) UTI/sepsishematoma (<1%) UTI/sepsis

obstruction injury to organobstruction injury to organ

-- contraindications :contraindications :

pregnancy calcified aneurysmpregnancy calcified aneurysm

morbid obesity bleeding diathesismorbid obesity bleeding diathesis

�� UreteroscopyUreteroscopy

�� Percutaneous nephrolithotomyPercutaneous nephrolithotomy

ESWL : Extra Corporeal Shock ESWL : Extra Corporeal Shock Wave LithotripsyWave Lithotripsy

Sebelum ESWLSebelum ESWL

Foto setelah ESWL

Foto setelah ESWLFoto setelah ESWL

STONE FREE RATESSTONE FREE RATES

proximal distalproximal distal

ureter ureterureter ureter

<1.0 cm<1.0 cm

ESWLESWL 84%84% 85%85%ESWLESWL 84%84% 85%85%

UreteroscopyUreteroscopy 56%56% 89%89%

PCNLPCNL 76%76% --

≥1.0 cm≥1.0 cm

ESWLESWL 72%72% 74%74%

UreteroscopyUreteroscopy 44%44% 73%73%

PCNLPCNL 74%74% --

STONE FRAGMENTATION TECHNOLOGIESSTONE FRAGMENTATION TECHNOLOGIES

�� Electrohydraulic lithotripsyElectrohydraulic lithotripsy

�� Holmium : YAG laserHolmium : YAG laser

�� Ballistic lithotripsy (pneumatic)Ballistic lithotripsy (pneumatic)�� Ballistic lithotripsy (pneumatic)Ballistic lithotripsy (pneumatic)

�� Ultrasonic lithotripsyUltrasonic lithotripsy

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