CASE REPORT

Ureterolithiasis 1/3 Proximal Sinistra + Nephrolithiasis

Dextra + Hydronephrosis Bilateral Grade IV
Kiki Rizki Arinda1, Marta Hendry2
1

Clinical Senior Clerkship, School of Medicine, Medical Faculty of Sriwijaya University, Dr.
Mohammad Hoesin General Hospital, Palembang
2
Department of Urology, School of Medicine, Medical Faculty of SriwijayaUniversity, Dr.
Mohammad Hoesin General Hospital, Palembang

Background: Urinary tract stones are made in the tubules of the kidney, and can
occupy the calix, infundibulum, renal pelvic, and even the whole calix. A stone may
stay in the kidney or travel down the urinary tract. A small stone (<5mm) may pass out
spontaneously through urinating, a larger stone may get stuck in the ureter
(ureterolithiasis) and can cause inflammation (periureteritis) along lead to chronic
obstruction (hydroureter or hydronephrosis). A stone that get stuck can block the flow
of urine, causing severe pain or bleeding. The lifetime prevalence of urinary tract stone
disease is estimated at 1% to 15%, with the probability of having stone varying
according to age, gender, race, and geographic location.

Clinical Presentation: A 46-year-old female patient came to Emergency Room of

Muhammad Hoesin General Hospital in Palembang with chief complain of right and left
side back pain since 1 week ago. The pain is intermittent. From the history of current
illness, the pain got worse followed by fever and bloody urine. From physical
examination, there was a knock pain in costovertebrae dextra and sinistra region.
Laboratory findings (19th February 2016) showed leucocytosis (12,2 x 103/mm3), and shift
to the left diff. count, an elevated BSS (346 mg/dL), from urinalysis examination
showed leucocytes (105-110/LFA), eritrocytes (124-126/LFA), and bacteria (+). This
patient already being hospitalized 10 days, and urine culture on 1st March 2016
showed bacteria (-), leucocytes 0-1/LFA, and epithel 0-1/LFA. From BNO-IVP
examination showed radio opaque stones in the calyces mayor of the right ureter and
1/3 proximal of the left ureter, also Hydronephrosis bilateral grade IV.
Discussion: Flank pain at the right and left side of back can be caused by urinary tract,
bowel, or gynecologic problem. From the anamnesis, there is no problem in lower
urinary tract or digestive tract. The knock pain in costovertebrae sinistra region indicate
the enlargement of the kidney and confirmed by IVP. BNO-IVP also show there is
radio opaque stones in the calyces mayor of right kidney right and 1/3 proxymal of left
ureter, also hydronephrosis grade IV bilateral.

Conclusion: Obesity and insuline resistence increased risk of stone-forming. Age,

gender, and life style also increase the probability of stone-forming. The urinary tract
stone growth usually caused by supersaturated urine and the crystals are formed. It can
be treated by medication or surgery. Diet factor and life style also have an important
role in prevention of the formation of urinary tract stone.

Keywords: Ureterolithiasis, nephrolithiasis, hydronephrosis.

Background

are special substances with high

The urinary tract can be divide

concentration in urine. Those

into three distinct; the kidneys,

substances are uric acid, calcium

the ureters and the bladder.

oxalate,

Urinary tract stones may stay in

cystine, struvite, and xantine, but

the kidney or travel down the

more than 80% of urinary tract

bladder via the ureters.1 A small

stone made of calcium stones,

stone (<5mm) may pass out

bind

spontaneously through urinating,

phosphate. 2

a larger stone may get stuck in the

ureter and can cause inflammation
(periureteritis)

along

lead

to

chronic obstruction (hydroureter

or hydronephrosis). A stone that
get stuck can block the flow of
urine, causing severe pain or
bleeding. Anatomically, ureter has
a narrower diameter such as
ureteropelvic junction, crossing of
the

iliac

vessels,

and

the

calcium

with

either

phosphate,

oxalate

or

The prevalence of kidney stone

disease is estimated at 1% to 15%
with the probability of having a
stone varying according to age,
gender,

race

and

geographic

location. It has a high relapse rate

(50% in 5-10 years and 75% in 20
years).

Common

clinical

presentation are acute flank pain

and hematuria.4

ureterovesical junction, where the

Urinary tract stone occurrence is

stone from kidney can get stuck

relatively uncommon before age

2,3

there.

Urinary tract stones are stones

that formed in kidney when there

20 but peaks in incidence in the

fourth to sixth decades of life.
Women has lower incidence of
2

the stone disease compared with

purine, oxalate, and calcium, also

men due to the protective effect of

sedentary life.2,3,5

estrogen againts stones formation

in premenopausal women. Due to
the geographic distribution of
stone disease tends to roughly
follow environmental risk factors;
a higher prevalence of stone
disease is found in hot, arid, or
dry

climates

such

as

the

mountains, desert, or tropical

areas.

Obesity,

diabetic

and

hypertension were the other risk

factors closely associated with
stone-forming.

5,6

stones is expected to be linked

with the disturbance of urine flow,
metabolic disorders, urinary tract
infections, dehydration, and other
idiopatic causes. But generally,
there are two factors which can
facilitate the formation of urinary
tract stones, the intrinsic and
extrinsic factors. Intrinsic factor
are hereditary, age around 30 until
50 years old, and gender where
man is often than woman. While
extrinsic factor are geographyc,
climate and temperature, lack of
intake

and

the

high

concentration of calcium in water

consumed,

the

stones

can

formed in every part of urinary

tract, especially in places that
often experience urine static like
renal calyces system or urinary
bladder.2
The stone consists of crystals
composed

by

organic

or

anorganic substances dissolved in

urine. Those crystals remain in
metastable condition which is
influenced by temperature, pH,

The formation of urinary tract

water

Theoretically,

dietary

with

high

colloid and solute concentration

in urine, urine flow in urinary
tract, or there is corpus alienum in
urinary tract that becomes nidus.
When this metastable condition
disturbed, the crystals will be
presipitated to form the stone core
(nucleation).

Then,

the

aggregation occurs to pull another

substances, thus becoming the
larger

crystals.

crystals

forms

Aggregated
retention

by

attachment to urothelium and

precipitate another substances to
form a bigger stone. 2,5
The

most

common

stone

is

Calcium stone (>80%), this stone

can

be

formed

because

of
3

hypercalciuria,

hyperoxaluria,

and

hyperuricosuria,

hypocitricuria,

therapy often given to stone that

and hypomagnesuria.2,5

open

surgery.

Medicinal

does not interfere, the size less

than 5 mm, and there is no

The formation of stone also based

the components that can inhibit
the stone formation (such as
Magnesium,

citric

and

glycosaminoglycan). Magnesium
ion (Mg++) can bind to Oxalate
forming Magnesium Oxalate salt,
that makes the amount of Oxalate
++

binds with Calcium (Ca ) to form

Calcium

Oxalate

stone

will

decreased. While citric can inhibit

the stone formation by binding to
Ca++ formed a Calcium Citric salt,
that makes the amaoun of Ca

++

binding with oxalat or phosphate

can be decreased.

2,5

upper and middle ureter often

cause flank pain, the pain often
peristaltic

because
activity

the stone that caused obstruction,

infection, and disturbe the social
life of patient should be removed
immediately from the urinary
tract. With ESWL, the stone
broken into little fragments so
that it can be easily removed from
the urinary tract. Endourology
method is a minimal invasive
procedure to break the stone and
remove it through the device that
inserted directly to urinary tract
from uretra or small incision on
skin.

Types

of

endourology

methods is PNL (Percutaneous

Stones or other objects in renal,

intermittent

complete obstruction. Whereas

of

of

the

smooth

muscle of urinary tract increased

in attempt to pull out the stone

Nephro Lithoplaxy), lithotrypsy,

ureteroscopy,

and

dormia

extraction. Open surgery consist

of nephrolithotomy to take the
stone

at

kidney

and

ureterolithotomy to take the stone

at ureter. The indication of open
surgery for kidney stone are

from urinary tract.3

hydronephrosis, infection, severe

The stones can be removed from
urinary

tract

with

pain, and for staghorn stone.2,3,5

medicine,

solved by ESWL (Extracorporeal

Shock

Wave

Lithotripsy),

Clinical presentation

endourology, laparascopy surgery,

4

A female, 46 years old, came to

CVD, and no history of same diseases

Emergency Room of Muhammad Hoesin

in her family.

General Hospital in Palembang with chief

From the physical examination, general

complain of right and left sided back

examination was normal. On local

pain that getting worse since 1 weeks

examination, there was a knock pain in

ago. The pain was intermittent. The

both right and left costovertebrae

patient also complained about bloody

region. There is no bulging or

urine and fever.

Since 2 months before admission,

tenderness in suprapubic region.

patient felt right and left sided back

pain. The pain is intermittent. Feeling
pain while urinating (-), a stone like
black pebble found while urinating (+),
sensation of incomplete bladder
emptying (-), change of urine color (-),
the urinary stream when urinating
normal. The defecation is normal and
there is no fever, nausea or vomitting.
From the history of past illness, this
patient has the history of sided back
pain 10 years ago, 2 stones like black
pebble found while urinating, and this
patient has been diagnosed with
ureterolithiasis and recommended for
surgery, but the patient refused. About 3

Laboratory findings (17th February 2016)

showed leucocytosis (12,2 x 103/mm3),
and shift to the left diff. count, an
elevated BSS (346 mg/dL), from
urinalysis examination showed
leucocytes (105-110/LFA), eritrocytes
(124-126/LFA), and bacteria (+). This
patient already being hospitalized 10
days, and urine culture on 1st March
2016 showed bacteria (-), leucocytes 01/LFA, and epithel 0-1/LFA.
BNO-IVP examination of this patient
showed radio opaque stones in the
calix mayor of right kidney and 1/3
proximal of left ureter, also
hydronephrosis grade IV bilateral.

years ago, the sided back pain

reappears, the patient got recommended
for surgery and got referred from RSUD
Lahat to RSMH Palembang, but while
waiting for the surgery schedule, the
pain was disappear, so the patient ask to
go home without doing the surgery. She
has no history of diabetes melitus and

Figure 1. BNO, (13th February 2016, RSUD

Lahat)

Figure 3. IVP 60 minutes, (26th February 2016)

This patient was diagnosed with

Ureterolithiasis 1/3 proximal sinistra +
Nephrolitiasis dextra + Hydronephrosis
bilateral grade IV. The treatment for this
case is with open surgery, consist of
nephrolitotomy and ureterolithotomy.
Prognosis for this patient, quo ad vitam
is bonam and quo ad functionam is
dubia at bonam.
Discussion
From the anamnesis, Mrs. Erni, 46
Figure 2. IVP 30 minutes, (26th February
2016)

years old, felt right and left sided

intermittent back pain and got worse
since 1 week ago. There are some
organs that can cause intermittent or
flank pain like renal and ureter (stone,
hydronephrosis, pyelonephritis),

abdomen (from bowel, aortic abdominal

110/LPB), eritrocytes (124-126/LPB),

aneurysm), and gynecologic (ectopic

and bacteria (+).

pregnancy, ovarian cyst torsion or

From the radiology examination, BNO-

rupture). The urinary stream is normal

IVP examination of this patient showed

mean the lower urinary tract is normal.

radio opaque stones in the calyces

The peristaltic activity of smooth

mayor of the right kidney and 1/3

muscle of ureter increased in attempt to

proximal of the left ureter. From the

pull out the stone from urinary tract,

IVP both left and right kidney can be

can caused the colic pain and bloody

seen clearly indicate the renal function

urine. There is no abnormality in

still good, also showed hydronephrosis

defecation show the complaint does not

grade IV bilateral.

come from digestive tract. From the life

From the anamnesis, physical

examination, and additional
examination, the patient is diagnosed
with Ureterolithiasis 1/3 proximal
sinistra + Nephrolitiasis dextra +
Hydronephrosis bilateral grade IV, it is
planned to do the open surgery
(nephrolithotomy and
ureterolithotomy).
The prognosis for this patient, in term
vitam is bonam, and in term of
functionam is dubia ad bonam.

style, patient have a sedentary live, rare

to drink and like to hold urination.
Those kind of life style can increase the
risk factors to get urolithiasis.
According to physical examination, the
vital sign was within normal limit and
the specific examination is normal too
except the knock pain felt in
costovertebrae dextra et sinistra region,
show the probability of hydronephrosis.
The patient is obese with BMI 31,24.
There is no bulging or tenderness in
suprapubic region show there is no
urine retention.
From the additional examination, the
laboratory examination showed
leucocytosis (12,2 x 103/mm3), and shift
to the left diff. count. The examination
for clinical chemistry showed a high
BSS (346 mg/dL), ureum and creatinin
within normal value. From urinalysis
examination, leucocytes (105-

Conclusion
The prevalence of urinary tract
stone is increase with age and
occur in man more than woman.
The urinary tract stone growth
usually caused by supersaturated
urine and the crystals are formed.
A narrower place of ureter can
make the stone from kidney get
stuck, and cause flank pain, colic
pain also hematuria. It can be
7

treated by medication or surgery.

urinary tract stone. The stones can

Diet factor

be removed from urinary tract

have

an

and life style also

important

role

in

with medicine, solved by ESWL

prevention of the formation of

Shock

Wave

Lithotripsy),

endourology, laparascopy surgery,

and open surgery. Diet factor also
have

an

important

role

in

prevention of the formation of

kidney

stone.

Drink

water

enough, balance diet, enough

activity

will

decrease

the

probability to have urinary tract

stone.

(Extracorporeal
2. Purnomo BB. 2012. Dasar-Dasar
Urologi. Edisi Ketiga. Jakarta: CV.
Agung Seto.
3. McAninch JW, Lue TF. Smith &
Tanaghos General Urology 18th
Edition. In: Stoller ML. Urinary
Stone Disease. United States: The
McGraw-Hill. 2013. Chapter 17, p.
249-75.
4. Sahani DV. Kidney Stone Diagnosis
and Management. Harvard Medical
School. Massachusetts General

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5. Kavoussi LR, Novick AC, Partin
AW, Peters CA. Campbell-Walsh
Urology 10th Edition. In: Pearle MS,

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Surgeon of Washington.

Epidemiology, and Pathogenesis.

http://www.dcurology.net/kstones/in

Philadelphia: Elsevier. 2012. Chapter

dex.html accesed 1st March 2016;

20.00.

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Shammari E, Al Enezi SH. Risk
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