UROLITHIASIS

Basuki B Purnomo, Besut Daryanto, Kurnia Penta Seputra, Paksi

Satyagraha
DEPARTMENT OF UROLOGY
SAIFUL ANWAR HOSPITAL/ BRAWIJAYA MEDICAL FACULTY
MALANG
2014

LEARNING OBJECTIVES
At the end of medical school, the medical student will
be able to...
List risk factors for the most common types of kidney stones
Contrast differences between the clinical presentation of acute
renal colic versus an acute abdomen
Name 4 kidney stone chemical compositions
Describe the imaging study to diagnose kidney or ureteral stones
Describe 3 types of medications effective for relief of renal colic
pain
List 3 clinical situations that warrant urgent decompression of a
ureteral stone
List 2 types of medications that may help medical expulsion
therapy of a distal ureteral stone
Describe two medical prophylaxis options for hypercalciuria
List 2 common surgical techniques to manage a renal stone and a
ureteral stone that fails to pass with observation

Level of competence

Sumber: SKDI 2013

Level of competence

Sumber: SKDI 2013

Urologic Operations in Saiful Anwar

Hospital
Oct 2001 - Sept 2006

EPIDEMIOLOGY OF UROLITHIASIS
Renal calculi are the predominant cause
of urinary stone disease in the
industrialized western world
Annual incidence in U.S. up to 164 per
100,000 or 12% over lifetime (Rochester,
MN, 1979)
Male : female ratio = 3 : 1

Diseases Associated with Kidney Stones

Hypertension
Low Bone Density
Obesity

Epidemiologic aspects
Geography
Climatic & seasonal
factors
Water intake
Diet
Occupation
(Menon & Resnick, 2002)

Stress

Urolithiasis: Composition, frequency, causes

Composition

Frequency

Causes & Mechanism

Calcium oxalate
or calcium phosphate

70%80%

Hypercalciuria
Low urine volume
Hyperuricosuria
Hyperoxaluria
Low urine citrate

Uric acid

10%15%

Low urine pH, defect in renal

ammonium secretion

Magnesium ammonium
phosphate (struvite,
infection-related)

10%15%

Urine infection (urea-splitting

bacteria)

Cystine
Autosomal recessive

< 1%

Cystinuria, the four dibasic amino

acids are cystine, ornithine, lysine,
and arginine, hence the mnemonic:
COLA.

About 80% of stones are calcium

based, and about 80% of those are
calcium oxalate stones.

Etiology

(Evan et al, 2005)

Initial site of crystal deposition

(Evan et al, 2005)

Pro-stone forces & inhibitors

Pro-Stone Forces
Calcium

Stone Inhibitors

Uric Acid

Volume (dilution)

Oxalate

Citrate

Cystine

Alkaline urine

Infection

Risk factors

Risk factors

Pathophisiology

Infection Stones

Alkalinization of urine by urease producing

organism
urease

NH2-CO-NH2 + H2O 2NH3 + CO2

NH3 + H20 NH4+ + OH-

CO2 + H2O H2CO3

H2CO3

H + + HCO3- 2H + + CO3(pK: 10.1)

Clinical presentation

Physical Examination

Differential diagnosis of acute renal

colic in adults

Diagnosis

Abdominal Plain Photo: Bilateral staghorn calculi

IVU: Left Pelvic stone with

hydronephrosis

Ultrasonography

Stone

CT scan

Metabolic Stone
Evaluation

Classification of
Hyperoxaluria

Uric Acid Stones

Etio

Calcium

Infection

Urate

Oxalate

Urea-splitter
bacteri

Urate

Urine pH
Ro (opacity)

Non opaque

Medical treatment

Oxalate

AB, urine
acidification

Purine , urine
alkalinization

Dietary Characteristics of Patients with

Renal Stones

Urolithiasis: Dietary Factors The Busch

Bonus

Beer drinking results in a 53%

reduction in risk for urinary calculi

(*N.B.: unrelated to amount consumed!)

Kueger, JN et al: AJKD 28:195, 1996

INDICATIONS FOR URGENT

INTERVENTION WITH URINARY
STONES

Expectant management

Spontaneous stone passage within the distal ureter may be facilitated with drugs
that enhance expulsion. Such medical expulsion therapy (MET) includes alphablockers and calcium channel blockers, typically used in combination with
NSAIDs.

Medical Treatments

Dietary Modification

Citrate Therapy for Hypocitraturia

Invasive and minimally invasive

management

Treatment: ESWL

Treatment: Lithotripsy

URS: Ureterorenoscopy

Treatment: PCNL

Stone Fragments

Treatment: open surgery

Recurrency

Preventing Recurrent Stones

Increased fluid consumption

Calcium diet???

SUMMARY

I will not cut persons labouring

under the stone, but will leave
this to be done by men who are
practitioners of this work.
Hippocrates

Thank you