NEPHROLITHIASIS NEPHROLITHIASIS ::

Surgical treatment andSurgical treatment andmetabolic evaluationmetabolic evaluation

Dr. Syah Mirsya Warli, SpUDr. Syah Mirsya Warli, SpUDr. Bungaran Sihombing, SpUDr. Bungaran Sihombing, SpU

Urology Division, Surgery DepartmentUrology Division, Surgery DepartmentMedical Faculty, Medical Faculty, University of Sumatera Utara University of Sumatera Utara

PRESENTATIONPRESENTATION

Renal colicRenal colic - classically : flank pain, often acute in- classically : flank pain, often acute in onset, radiating to the ipsilateral onset, radiating to the ipsilateral

abdomenabdomen - 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 & wanes- waxes & 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 : - 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) Urinary infectionUrinary infection Fever, esp if infection presentFever, esp if infection present Occasionally asymptomatic, with Occasionally asymptomatic, with

stones detected incidentallystones detected incidentally

PAST MEDICAL HISTORYPAST MEDICAL HISTORY

fluid intakefluid intake Urinary tract infectionUrinary tract infection High-protein diet (associated with High-protein diet (associated with

acidosis, hypocitraturia, hypercalciuria, acidosis, hypocitraturia, hypercalciuria, hyperuricosuria, hyperoxalouria)hyperuricosuria, hyperoxalouria)

Intestine Bowel Disease, small bowel Intestine Bowel Disease, small bowel resection, jejunoileal bypass resection, jejunoileal bypass (hyperoxaluria & Ca oxalate stones)(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)

Renal Tubular Acidosis (Ca phosphate Renal Tubular Acidosis (Ca phosphate stones)stones)

Medication :Medication : - steroids (hypercalciuria)- steroids (hypercalciuria) - loop diuretics (hypercalciuria)- loop diuretics (hypercalciuria) - colchicine (hyperuricosuria)- colchicine (hyperuricosuria) - vitamin D- vitamin D - antacids- antacids - triamterene- triamterene - indinavir- indinavir

Associated Genito Urinary diseases:Associated Genito Urinary diseases: - UPJ obstruction - UPJ obstruction - bladder reconstruction- bladder reconstruction - BPH- BPH - 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 risk risk

EVALUATION IN THE ACUTE EVALUATION IN THE ACUTE SETTINGSETTING

PHYSICAL EXAMPHYSICAL EXAM

- evaluate for fever- evaluate for fever

concomitant infection may beconcomitant infection may be

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

hypertensionhypertension

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

tenderness/peritonitistenderness/peritonitis

URINALYSIS AND URINE URINALYSIS AND URINE CULTURECULTURE

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 stone uric acid stone

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

& hyper chloremia & hyper chloremia RTA RTA

> 6.0 > 6.0 struvit struvit Crystals :Crystals : - Ca oxalate - Ca oxalate dumbbell/hourglass/bipyramidal dumbbell/hourglass/bipyramidal

- Ca phosphate - Ca phosphate needle-shaped/amorphous needle-shaped/amorphous

- uric acid - uric acid amprphous/rosettes amprphous/rosettes

- struvite - struvite coffin lid coffin lid

- cystine - cystine benzene ring/hexagonal benzene ring/hexagonal

SERUM STUDIESSERUM STUDIES

Complete blood countComplete blood count ElectrolytesElectrolytes CalciumCalcium PhosphatePhosphate Uric acidUric acid

IMAGINGIMAGING

KUBKUB

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

calyxcalyx

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 setting- nowadays, rarely used in the acute setting

UltrasoundUltrasound

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

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

stonesstones

IVPIVP

USG

Non-contrast computed tomographyNon-contrast computed tomography

- 97% sensitive & 97% specific for - 97% sensitive & 97% specific for stonestone

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

hydroureterhydroureter

hydronephrosis hydronephrosis

perinephric strandingperinephric stranding

nephromegalynephromegaly

ACUTE MANAGEMENTACUTE MANAGEMENT

Pain control : - narcoticsPain control : - narcotics - NSAIDS- NSAIDS IV fluidsIV fluids AB if urinary infection (+)AB if urinary infection (+) Strain urineStrain urine Recommended indication for admission :Recommended indication for admission : - uncontrolled pain- uncontrolled pain - unremitting nausea/vomiting - unremitting nausea/vomiting - obstructed, infected renal unit- obstructed, infected renal unit - obstructed, solitary renal unit- obstructed, solitary renal unit - bilateral obstruction- bilateral obstruction - anuria- anuria

Recommended indication for watchful Recommended indication for watchful waitingwaiting

- no evidence of infection- no evidence of infection - pain well-controlled with oral medication- pain well-controlled with oral medication - stone < 5 mm- stone < 5 mm - no obstruction- no 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 Spontaneous passage rates within 1 year :year :

< 4 mm< 4 mm 90%90%

4 – 6 mm4 – 6 mm 60%60%

> 6 mm> 6 mm 20%20%

Obstruksi ureter akut

Peningkatan tekanan pelvis renalis

Nyeri meningkat

prostaglandin

diuresis

Suspresi hormon anti diuretikVaso dilatasi ginjal

Obstruksi ureter akut

Peningkatan tekanan pelvis renalis

Edema perirenal dan periureter

Kerusakan ginjal :terjadi oleh karena iskhemia infark / nekrosis pada duktus koligentes dan

tubulus proksimalis

Dilatasi pelvis renalis

MEDICAL OPTIONS DURING MEDICAL OPTIONS DURING EXPECTANT MANAGEMENTEXPECTANT MANAGEMENT

Pain controlPain control AB prophylaxisAB prophylaxis Alpha blockersAlpha blockers Ca channel blockersCa channel blockers steroidssteroids

SURGERYSURGERY

ESWLESWL - imaging : fluoroscopy- imaging : fluoroscopy - anesthesia : sedation or general- anesthesia : sedation or general - potential long-term renal effect :- potential long-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 pregnancy calcified

aneurysmaneurysm morbid obesity bleeding diathesismorbid obesity bleeding diathesis

UreteroscopyUreteroscopy Percutaneous nephrolithotripsyPercutaneous nephrolithotripsy

ESWL : Extra Corporeal Shock ESWL : Extra Corporeal Shock Wave Lithotripsy Wave 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 cmESWLESWL 84% 84% 85% 85%UreteroscopyUreteroscopy 56% 56% 89% 89%PCNLPCNL 76% 76% - -

≥≥1.0 cm1.0 cmESWLESWL 72% 72% 74% 74%UreteroscopyUreteroscopy 44% 44% 73% 73%PCNLPCNL 74% 74% - -

STONE FRAGMENTATION STONE FRAGMENTATION TECHNOLOGIESTECHNOLOGIES

Electrohydraulic lithotripsyElectrohydraulic lithotripsy Holmium : YAG laserHolmium : YAG laser Ballistic lithotripsy (pneumatic)Ballistic lithotripsy (pneumatic) Ultrasonic lithotripsyUltrasonic lithotripsy

WR’08