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Urinary Stone Disease
Dr.Moh.Galuh Richata, SpU
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Prologue
Urinary Stone Disease (urinary calculi,
urolithiasis) is the disease with
development of stones in the urinary tract.
Its the 3rd most common disease in the
urinary tract, after infections and prostate
disease.
Its have plagued humans since the
earliest records of civilization.
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Nomenclature
Urinary Tract Stones Urolithiasis
Kidney Stones Nephrolithiasis
Pyelum: Pyelolithiasis Calix: Calix stones
Pyelum + Calix : Staghorn stones
Ureter Stones
Ureterolithiasis Bladder Stones Vesicolithiasis
Urethra Urethrolithiasis
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Etiology
Theory of Stone Formation is still incomplete
and debatable.
Polycrystalline aggregates composed of varying
amounts of crystalloid and organic matrix. Stone formation requires supersaturated urine.
Supersaturat iondepend on: urinary pH, ionic
strength, solute concentration, andcomplexation.
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Urinary Ions
1. Calcium (major ion in urinary crystals)2. Oxalate (normal waste of metabolism)
3. Phosphate (important buffer, complexeswith calcium)
4. Uric Acid (product of purine metabolism)
5. Sodium (regulates crystallization ofcalcium salts)
6. Citrate (affect the development ofcalcium stones, but can inhibit stoneinformation)
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7. Magnesium (component of struvitestones, can inhibit stone information)
8. Sulfates (may help prevent stone
formation)9. Other Urinary Stone Inhibitors:
glycosaminoglicans, pyrophosphates,
uropontin.
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Stone Varieties
A. Calcium Calculi:1. Absorptive Hypercalciuric Nephrolithiasis
2. Resorptive Hypercalciuric Nephrolithiasis
3. Renal induced Hypercalciuric Nephrolithiasis4. Hyperuricosuric Calcium Nephrolithiasis
5. Hyperoxaluric Calcium Nephrolithiasis
6. Hypocitraturic Calcium Nephrolithiasis
B
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B. Non Calcium Calculi:1. Struvite (MAP = magnesium ammonium
phosphate, frequently as staghorn stones)
2. Uric Acid
3. Cystine
4. Xanthine (deficiancy of xanthine oxidase)
5. Indinavir
6. Others
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Sign & Symptoms
of Upper Urinary Tract Stones
A. Pain: 2 types of pain origin from kidney:
Renal Colic (caused by stretching of the
collecting system or ureter)
Noncolicky Renal Pain (caused by the
distention of the renal capsule)
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Renal Colic
Can come in waves, but also may berelatively constant.
The onset can be very sudden and severe.
Patients frequently move constantly tryingto relieve the pain.
The severity and location of the pain can
vary, depends on: stone size, stonelocation, degree of obstruction, acuity of
obstruction, and variation of anatomy.
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Sign & Symptoms
B. Hematuria:Can be gross (macroscopic) or microscopic
hematuria.
Most patients will have at least microscopichematuria.
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Sign & Symptoms
C. InfectionAll stones may be associated with urinary tract infection,secondary to obstruction and stasis proximal to the stonewhich has caused the obstruction.
Any urinary infection can lead to urosepsis. Sign of
sepsis: fever, tachycardia, hypotension, tachypnea.
D. Nausea and Vomitting
Frequently associated with upper urinary obstruction.
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Diagnosis
A. History Taking
Pain (onset, character, radiation,
activities), Nausea/vomit, gross
hematuria, fever, cloudy urine, passing
stone/sand. Voiding disorders.
B. Physical Examination
General Condition (in pain,
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Diagnosis
B. Physical Examination
General Condition (gestures in pain, body
temperature, heartbeat, etc)
Flank region (ad regio lumbalis):
inspection, palpation, percussion
(costovertebral angle).
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Diagnosis
Laboratory Examination
Blood: Hb, Leukocyte, Ureum, Creatinine,
Uric Acid
Urine: pH, Erythrocyte, Leukocyte,
Sediments (crystal, bacteria, epithelium).
Urine Culture (type, colony counts, resistant
test)
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Diagnosis
Imaging (radiologic investigations)- Ultrasound
- Plain Abdomen (KUB/BNO)
- Intravenous Pyelography/Urography(IVP/IVU)
- Retrograde Pyelography
- Computed Tomography Scan- Magnetic Resonance Imaging
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Intervention
1. Conservative Observation
Ureter stones can spontaneously pass but
depends on: stone size, shape, location,
ureteral edema (duration of stay).Stone 4-5 mm have 40-50% chance of pass
Stone > 6 mm have 5 %.
Sometimes need specific drug to help thestone to pass.
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Intervention
2. Dissolution Agents
Very depends on stone surface area,
stone type, volume of irrigant, mode of
delivery, kidney function.
Only effective on small stones (
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Intervention
3. Open Surgery (Nephrolithotomy, etc)
4. Endoscopic Surgery:
URS (Ureterorenoscopy)
PNL (Percutaneous Nephro-Litholapaxy).
5. ESWL (Extracorporeal Shock Wave
Lithotripsy)
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Lower Urinary Tract Stones
Bladder Stones
> The surgery of bladder stones is one ofthe three oldest surgical procedure known
in human history.> Etiology of bladder stones:
Underlying bladder outlet disorders
Foreign bodies (IUD, worms, etc) Systemic/Metabolic disorders (children
with malnutrition)
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Diagnosis
of Bladder Stones
History: Irritative voiding symptoms,
intermittent urinary stream, urinary tract
infections, pelvic pain.
Physical Examination:
- General condition
- Lower Abdominal Region (Suprapubic)- Digital Rectal Examination
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Diagnosis
of Bladder Stones
Laboratory: urine
Imaging: Ultrasound, KUB/BNO
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Intervention
- Open Surgery (Vesicolithotomy, Sectio
Alta)
- Endoscopic Surgery: Cystoscopy &
Lithotripsy
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