Dr.Moh.

Galuh Richata, SpU

 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.
 Urinary Tract Stones Urolithiasis
Kidney Stones Nephrolithiasis
Pyelum: Pyelolithiasis
Calix: Calix stones
Pyelum + Calix : Staghorn stones
Ureter Stones Ureterolithiasis
Bladder Stones Vesicolithiasis
Urethra Urethrolithiasis
 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.
Supersaturation depend on: urinary pH, ionic
strength, solute concentration, and complexation.
1. Calcium (major ion in urinary crystals)
2. Oxalate (normal waste of metabolism)
3. Phosphate (important buffer, complexes with
calcium)
4. Uric Acid (product of purine metabolism)
5. Sodium (regulates crystallization of calcium salts)
6. Citrate (affect the development of calcium stones,
but can inhibit stone formation)
7. Magnesium (component of struvite stones, can inhibit
stone information)
8. Sulfates (may help prevent stone formation)
9. Other Urinary Stone Inhibitors: glycosaminoglicans,
pyrophosphates, uropontin.
A. Calcium Calculi:
1. Absorptive Hypercalciuric Nephrolithiasis
2. Resorptive Hypercalciuric Nephrolithiasis
3. Renal induced Hypercalciuric Nephrolithiasis
4. Hyperuricosuric Calcium Nephrolithiasis
5. Hyperoxaluric Calcium Nephrolithiasis
6. Hypocitraturic Calcium Nephrolithiasis

B
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
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)
 Can come in waves, but also may be relatively
constant.
The onset can be very sudden and severe.
Patients frequently move constantly trying to relieve
the pain.
The severity and location of the pain can vary, depends
on: stone size, stone location, degree of obstruction,
acuity of obstruction, and variation of anatomy.
B. Hematuria:
Can be gross (macroscopic) or microscopic hematuria.
Most patients will have at least microscopic hematuria.
C. Infection
All stones may be associated with urinary tract infection,
secondary to obstruction and stasis proximal to the stone
which 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.
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,
B. Physical Examination
General Condition (gestures in pain, body
temperature, heartbeat, etc)
Flank region (ad regio lumbalis): inspection, palpation,
percussion (costovertebral angle).
 Laboratory Examination
Blood: Hb, Leukocyte, Ureum, Creatinine, Uric Acid
Urine: pH, Erythrocyte, Leukocyte, Sediments (crystal,
bacteria, epithelium).
Urine Culture (type, colony counts, resistant test)
 Imaging (radiologic investigations)
- Ultrasound
- Plain Abdomen (KUB/BNO)
- Intravenous Pyelography/Urography (IVP/IVU)
- Retrograde Pyelography
- Computed Tomography Scan
- Magnetic Resonance Imaging
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 the stone
to pass.
2. Dissolution Agents
Very depends on stone surface area, stone type, volume
of irrigant, mode of delivery, kidney function.
Only effective on small stones (<5 mm).
Not recommended on obstructing stones.
3. Open Surgery (Nephrolithotomy, etc)
4. Endoscopic Surgery:
URS (Ureterorenoscopy)
PNL (Percutaneous Nephro-Litholapaxy).
5. ESWL (Extracorporeal Shock Wave Lithotripsy)
Bladder Stones
> The surgery of bladder stones is one of the 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)
 History: Irritative voiding symptoms, intermittent
urinary stream, urinary tract infections, pelvic pain.
Physical Examination:
- General condition
- Lower Abdominal Region (Suprapubic)
- Digital Rectal Examination
 Laboratory: urine

Imaging: Ultrasound, KUB/BNO

- Open Surgery (Vesicolithotomy, Sectio Alta)
- Endoscopic Surgery: Cystoscopy & Lithotripsy