Batu Saluran Kemih

(Urolithiasis)

Prof. Doddy M. Soebadi, MD, PhD

Dept. of Urology
Soetomo General Hospital Airlangga Univ. School of Medicine
DMS 2011 Surabaya 1
 URINARY TRACT STONE

4800 BC batu dalam tlg pelvis mummi (Elliot

Smith 1901)
Asutu-Mesopotamia (3200 - 1200 SM) naskah
gejala & terapi BSK
SusruthaSamhita (600 SM - 600 M)
1772-1851 HCG von Struve : batu struvit
stone belt

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 UROLOGI

I WILL NOT CUT, EVEN FOR THE STONE,

BUT LEAVE SUCH PROCEDURES TO THE
PRACTITIONERS OF THE CRAFT
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Hippocrates 500y BC
 Hippocrates described the symptoms of renal
colic:
An acute pain is felt in the kidney, the loins, the
flank and the testis of the affected side; the
patient passes urine frequently; gradually the
urine is suppressed. With the urine, sand is
passed.

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 Epidemiology
Upper urinary tract stones occur more commonly
in men than women, but there is evidence that
the gender gap is narrowing.
Whites have the highest incidence of upper tract
stones compared with Asians, Hispanics, and
African-Americans.
Prevalence of stone disease shows geographic
variability
The risk of stone disease correlates with weight
and body mass index
 URINARY TRACT STONE

CLASSIFICATION
2 groups:

1. MIAF: definitive causes:

M : metabolic
I : infection
A : anatomic
F : functional

2. Idiopathic

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 URINARY TRACT STONE

MIAF Urolithiasis

Defects in purine metabolism (uric acid related disorders)

Hyperoxaluric states
Primary hyperoxaluria
Enteric hyperoxaluria
Hypercalcemic states
Primary hyperparathyroidism
Hyperthyroidism
Vitamin D abuse

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 URINARY TRACT STONE

MIAF Urolithiasis

Hypercalcemic states (cont.)

Immobilization
Disseminated malignancies
Sarcoidosis
Renal tubular acidosis
Chronic diarrhoeal states
Cystinuria
Urinary infection with urease producing microorganisms
Anatomical and functional abnormalities

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 URINARY TRACT STONE

RISK FACTORS

Genetics :
Cystinuria: autosomal recessive
RTA (renal tubular acidosis) type I
Medullary sponge kidney
Geography : temperature & humidity
Diet : calcium / oxalate intake >>
Profession: sedentary

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 URINARY TRACT STONE

Age Profession Nutrition Climate Inheritance

Sex Mentality Constitution Race

Abnormal renal Disturbed Urinary Metabolic Genetic

morphology urine flow tract infection abnormalities factors

Increase Decreased

excretion of excretion of Excretion of Urinary volume

stone forming crystallization crystallization
constituents promoters inhibitors

Physico-chemical change in the

state of supersaturation

Abnormal crystalluria
Crystal aggregation
Crystal growth

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DMS 2011 11
 URINARY TRACT STONE

DIAGNOSIS

History
Physical exam.
Additional :
Urine, microbiology
Serum: kidney function, uric acid
Plain x-ray / USG /IVP

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 Composition of most important stone constituents

Chemical name Mineral name

-------------------------------------------------------------------------------------------
Oxalate Ca Ox Monohydrate Whewellite
Ca Ox dihydrate Weddwlite
Phosphate Carbonate appatite Dahllite
Ca H Ph dihydrate Brushite
b-tri Ca phosphate Whitlockite
Hydroxyapatite
Mg Am phosphate hex. Struvite
Uric acid Uric acid Uricite
Urate Uric acid dihydrate -
Mono amm.urate -
Mono so. urate monohyd. -
Stone associated w/ L-cystine -
Inborn error of metab.Xanthine -
2,80Dihydroxyadenine -

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 BASIC METABOLISM EVALUATION

HISTORY
X-RAY
STONE ANALYSIS
BLOOD:
SERUM CREATININE
CALCIUM
URIC ACID
URINE:
CULTURE
pH

NEFROLITIASIS KALSIUM NEFROLITIASIS KALSIUM

IDIOPATIK SEDERHANA IDIOPATIK KOMPLIKASI
EVALUASI SELEKTIF
TAMBAHAN
TAK PERLU EVALUASI
SELANJUTNYA EVALUASI METABOLIK LUAS
UROLITIASIS
MIAF
URIN 24 JAM
MINUM > BANYAK S.KREATININ
KALSIUM
SITRAT
TERAPI SESUAI
KELAINAN DASAR

MINUM LEBIH BANYAK

HIPER-KALSIURIA ----- TX THIAZIDE
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HIPO-SITRATURIA ----- TX K-- SITRAT
 MANAGEMENT OF URINARY TRACT STONE

EVALUASI METABOLIK DASAR

Anamnesa: peny. GI, tulang, dsb, RPK, diit,
obat2an
Foto polos abd., IVP, USG
Pem. Urin: UL, biakan, pH
Analisa batu
Pem. Darah: kreatinin, urat, kalsium

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 URINARY TRACT STONE

EVALUASI METABOLIK LUAS

Urin 24 jam:
volume
kreatinin
kalsium
sitrat

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 MANAGEMENT OF URINARY TRACT STONE

TERAPI

PENGAMBILAN BATU

1. ESWL
2. URS
3. PNL
4. LAPAROSKOPIK
5. BEDAH TERBUKA

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 KEY POINTS: URETERAL CALCULI
Conservative management: ureteral stone smaller
than 5 mm (MET=MEDICAL EXPULSIVE THERAPY)
Ureteral stones larger than 5 mm are unlikely to
pass spontaneously.
Obstructed pyelonephritis due to a ureteral stone
not uncommon
potentially life-threatening emergency
best treated by urgent decompression of the urinary
tract
Both SWL and ureteroscopy are highly effective
for patients with ureteral calculi.
MET with agents such as tamsulosin may promote
spontaneous stone passage
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 KEY POINTS: RENAL CALCULI
Majority of patients : renal calculi have a normal kidney
and a small stone burden, and can be managed best with
SWL.
lower pole calculi larger than 10 mm significantly better
stone-free rates after PNL than after SWL.
The procedure of choice for staghorn calculi is PNL. When
left untreated, staghorn calculi loss of renal function
and increased mortality.
Patients harboring stones that are resistant to
fragmentation (cystine, brushite, calcium oxalate
monohydrate) should undergo SWL only when the stone
burden is small.
PNL for calculi in calyceal diverticula provides the best
chance for a stone- and symptom-free outcome.
The outcome of PNL is independent of the patient's body
mass index, and therefore PNL is a good treatment option
for the morbidly obese with a large stone burden. For the
DMS 2011
morbidly obese with a small stone burden, ureteroscopy19
is
the optimal approach
 MANAGEMENT OF URINARY TRACT STONE

Perlu tindakan urgen / segera:

1. Ada bakteriemia atau sepsis
2. Profesi tertentu, tidak melihat ukuran batu
(preventif):
1. Pilot
2. Insinyur / pekerja konstruksi
3. Dokter spesialis bedah
(serangan kolik membahayakan orang lain
atau diri sendiri)

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 MANAGEMENT OF URINARY TRACT STONE

Pedoman terapi ekspektatif (= MET):

1. Ukuran 4 mm atau lebih kecil

2. Keluhan tidak mengganggu
3. Tidak ada ISK (biakan, febris, mengigil)
4. Tidak ada obstruksi (hidronefrosis)
5. Maksimum 4-6 minggu

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 MANAGEMENT OF URINARY TRACT STONE

Perlu diperhatikan untuk terapi ekspektatif:

1. Anamnesa yang cermat (keluhan)

2. Foto polos abd. (BOF) atau USG
3. IVP
4. Biakan urin
5. Penderita ko-operatif

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 MANAGEMENT OF URINARY TRACT STONE

Terapi ekspektatif:

1. Diuretika :
HCT 25 mg 1 X 1 tab
2. K/p analgetik (bl kolik) :
An algetika (hati2 NSAID)
3. Exercise : lari, olah raga yg loncat2
Jogging, badminton, tennis : 3 X 20 men / minggu
4. Minum 3-4 liter air
Bila faal ginjal normal
5. Jangan diberi antibiotika
ISK + indikasi tindakan
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 MANAGEMENT OF URINARY TRACT STONE

Terapi antibiotika: hanya diberikan pada keadaan:

1. Gejala bakteriemia atau urosepsis:

1. Febris atau subfebris o;k; ISK
2. Menggigil
3. Antibiotika segera diberikan dan segera dilakukan tindakan
definitif
2. Akan dilakukan tindakan atau operasi
3. Batu sudah keluar / diambil / bersih, masih ada infeksi
(hasil kultur positif)

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 Phisicochemistry
Urine must be supersaturated for stones to form.
Supersaturation alone is not sufficient for crystallization to
occur in urine, owing to the presence of urinary inhibitors.
Nephrocalcin, uropontin, and Tamm-Horsfall protein are
important inhibitors of crystal nucleation, growth, or
aggregation.
Urinary calcium and oxalate are equal contributors to urinary
saturation of calcium oxalate.
Common calcium stones may originate from subepithelial
plaques composed of calcium apatite that serve as an anchor
on which calcium oxalate stones can grow.
The non crystalline component of stones is matrix, which is
composed of a combination of mucoproteins, proteins,
carbohydrates, and urinary inhibitor
 Dietary recommendations

Randomized studies have confirmed the

advantage of a diet with:

1. reduced animal protein (meat) intake

2. high in fruits and vegetables
3. sodium restriction