+

BATU SALURAN KEMIH

DODY EFMANSYAH
Sub Bagian Bedah Urology FK-UNAND / RSUP DR M
DJAMIL

REF :
Panduan Praktek Klinil Batu
Saluran Kemih ( PPK-BSK ). IAUI,
2005
Bailey & Loves Short Practice of
Surgery 26th Ed. Page 1292-1297
Guidelines on Urolithiasis.
European Association of Urology
2015

OPTIMAL CLINICAL MANAGEMENT

REQUIREMENT
1.
2.
3.
4.
5.
6.

ETIOLOGY
METABOLIC OF STONE
FORMATION
DIAGNOSTIC PROCEDURE
RATIONAL TREATMENT
STONE REMOVAL METHODS
PREVENTION RECURRENCIES

+
Introduction
Insidens

tergantung geografi, iklim, etnis,

kebiasaan makan dan faktor genetik
Prevalence rate : 1% to 20%
Lifetime rate ; 5 -10 %
Resiko Kambuh tergantung pada temuan
gangguan yang menyebabkan terbentuk nya
batu.

Pada negara dgn standar hidup yang tinggi

( Swedia, Canada , US ) , prevalensi > 10%

Pada beberapa negara peningaktan > 37 % (20 tahun

terakhir )

+
ETIOLOGY
Subject is complex and then following
represents a brief summary of currrent
opinion
1.
2.
3.
4.
5.
6.
7.

Dietetic ( Vit A epithellium desquamation Nidus )

Altered urinary solutes and colloids
Decreased urinary citrate ( inhibitory fsctors )
Renal infection ( urea splitting bacteria )
Inadequate urinary drainage and stasis
Prolonged immobilisation ( increase urinary calcium )
Hyperparathyroidsm

+ Stone Classified by ETIOLOGY

NON
INFECTION
STONES

CALCIUM OXALAT
CALCIUM PHOSPHAT
URIC ACID
MAGNESIUM AMMONIUM PHOSPHAT

INFECTION
STONES

CSRBONATE APATITE
AMMONIUM URAT

GENETIC
CAUSES

CYSTINE
XANTHINE
2,8 -DIHYDROXYADENINE

DRUGS STONE

INDINAVIR

+
Risk groups for stone
formation
The

risk status of stone formers is of

particular interest because it defines the
probability of recurrence or regrowth, and
is imperative for pharmacological
treatment.

50%

of recurrent stone formers have just one

lifetime recurrence.

Highly

recurrent disease is observed in

slightly more than 10% of patients.

Stone

type and disease severity determine

low or high-risk of recurrence

High-risk stone formers

GENERAL FACTORS
Early onset, Familial, solitary kidney
Brushite, uric acid and urate containing stones, infection stones
DISEASEAS ASSOCIATED STONE FORMATION
Hyperparathyroidism, metabolic syndrome, nephrocalciosis
Bastrointestinal diseases, sarcoidosis
GENETIC DETERMINED STONE FORMATION
Cystinuria, hiperoxalouria, RTA, xantinuria, cystic fibrosis
DRUGS ASSOCITED STONE FORMATION
ANATOMICAL ABNORMALITIES, ASSOC with STONE
FORMATION
Medullary Sponge Kidney, calyceal diverticulum, UPJ Stenosis,
horseshoe
Ureteral stricture, VUR, ureterocele

Classification of stones

STONE SIZE ( mm )
0-5

5-10

10-20

>20

STONE LOCATION
RENAL

URETER

PELVIC, UC, ML. LL

UPPER, MIDDLE, DISTAL

BLADDER

X-RAY CHARACTERISTIC
RADIOOPAQUE

POOR RADIOOPACITY

RADIOLUSCENT

Ca Ox Di

Mg Ammo Phosphat

Uric Acid

Ca Ox Mono

Apatite

Ammo Urate

Cal Phosphate

Cystine

Xanthine
2,8 dihidro
Drug Stone

+
ETIOLOGY, PHYSICOCHEMISTRY

STATE OF SUPERSATURATION

SALT COMPONENT & CONCENTRATION, INHBITORS,

PROMOTERS

NUCLEATION AND CRYSTAL GROWTH, AGGREGATION

AND RETENTION

+
STONE COMPOSITION

CHEMICAL NAME : calcium Oxalate Mono Hidrate

CHEMICAL FORMULA :

MINERAL NAME :

CaC2O4.H2O

WHEWELITE

WHEDELITE
APATITE
HYDROXY APATITE
BRUSHITE
STRUVITE

DIAGNOSIS

ANAMNESA
Keluhan

bervariasi mulai dari tanpa

keluhan, sakit pinggang ringan
sampai dengan kolik, disuria,
hematuria, retensio urin, anuria.

Keluhan

ini dapat disertai dengan

penyulit berupa demam, tandatanda gagal ginjal

PEMERIKSAAN FISIK

bervariasi mulai tanpa kelainan fisik sampai tandatanda sakit berat tergantung pada letak batu dan
penyulit yang ditimbulkan.

Pemeriksaan fisik umum : hipertensi, febris,

anemia, syok

Pemeriksan fisik khusus urologi

Sudut kosto vertebra : nyeri tekan , nyeri ketok,

pembesaran ginjal

Supra simfisis : nyeri tekan, teraba batu, buli-buli penuh

Genitalia eksterna : teraba batu di uretra

Colok dubur : teraba batu pada buli-buli (palpasi

bimanual)

+
PEMERIKSAAN LABORATORIUM
URINALISA
eritrosituri,

lekosituria, bakteriuria
(nitrit), pH urin dan
kultur urin.
Pemeriksaan
hemoglobin,

darah berupa

lekosit,
ureum dan kreatinin.

+ Recommendations: basic lab analysis

emergency urolithiasis patients (EAU

2016)
URINE
DIPSTICK Test of SPOT URINE SAMPLE
( RBC, WBC, Nitrite )
URINE MICROSCOPY and or Culture
pH
BLOOD
Serum blood
Creatinin
Sample
Uric Acid
Ca ( ionized ), Na, K
Blood Cell Count
CRP

Gr
A
A

+
PENCITRAAN

Pemeriksaan rutin meliputi

Pemeriksaan dengan contrast media tidak dilakukan

pada pasien-pasien berikut :

foto polos perut (KUB) dengan pemeriksaan

ultrasonografi atau intravenous pyelography (IVP)
atau spiral CT.

Dengan alergi kontras media

kreatinin serum > 200mol/L (>2mg/dl)
Dalam pengobatan metformin
Dengan myelomatosis

Pemeriksaan khusus yang dapat dilakukan meliputi :

Retrograde atau antegrade pyelography

Scintigraphy

+
Diagnostic imaging
Ultrasound

(US / USG) should be used as the

primary diagnostic imaging tool :

US is safe (no risk of radiation), reproducible and

inexpensive.
It can identify stones located in the calices, pelvis,
and PUJ, UPJ, as well as in patients with upper
urinary tract dilatation.
sensi of 45% and speci of 94% for ureteric stones
and 45% and 88% for renal stones

The

sens and spec of KUB is 44-77% and 80-

87%

KUB should not be performed if NCCT is considered,

however, it is helpful in differentiating between
radiolucent and radiopaque stones and for comparison

+
Evaluation of patients with
acute flank pain

NCCT has become the standard for diagnosing acute

flank pain, and has replaced intravenous urography
(IVU).

NCCT can determine stone diameter and density.

When stones are absent, the cause of abdominal pain

should be identified.

In evaluating patients with suspected acute urolithiasis,

NCCT seems to be significantly more accurate than IVP

+
Radiation exposure of
imaging modalities
METHODES
KUB
IVU
REGULAR DOSE of
NCCT
Low DOSE of NCCT

Enhance CT

RADIATION
EXPOSURE
0,5 - 1
1.3 3.5
4,5 5
0,97 1,9
(patients with BMI <
30)
25 - 35

+
DIAGNOSTIC PROCEDURE

If available, USG should be used as the primary diagnostic

imaging tool. US is safe (no risk of radiation), reproducible
and inexpensive.

It can identify stones located in the calices, pelvis, and

pyeloureteric and vesicoureteric junctions, as well as in
patients with upper urinary tract dilatation.

For stones > 5 mm, US has a sensitivity of 96% and specificity

of nearly 100% (1). For all stone locations, sensitivity and
specificity of US reduces to 78% and 31%, respectively (1).

The sensitivity and specificity of KUB radiography is 4477% and 80-87%, respectively.

KUB radiography should not be performed if NCCT is considered

, however, it is helpful in differentiating between radiolucent
and radiopaque stones and for comparison during follow-up.

+
STONE ANALYSES

ALL PATIENTS SHOULD HAVE AT LEAST ONE STONE

ANALYSES

INFRARED

S P E C T R O S C O P Y ( IRS )

X RAY

Chemical analysis (wet chemistry) is generally deemed to be

obsolete

DIFFACTION (XRD)

STONE COMPOSITION MAY BE ASSESED

RADIOGRAPHYC CHARACTERISTIC

URINARY SDIMENT ( CRYSTAL FOR STRUVIT OR CYSTINE )

URINE pH

BACTERIA / URINE CULTURE

QUALITATIVE CYSTINE TEST.

+
TREATMENT
RENAL COLIC
DICLOVENAC
CONTINUE

SODIUM

FOR 7-10 DAYS, 2- 3 X 50MG

FACILITATED

STONE PASSAGE WITH ALPHA

BLOCKING AGENT TAMSULOZIN

Diclofenac can affect renal function in patients

with an already reduced function; however,
there is no effect if the kidneys are functioning
normally

+
Indication for
ACTIVE STONE REMOVAL

STONE DIAMETER > 5 mm ( IND 5-6 mm )

ADEQUATE PAIN RELIEVE CANNOT BE ACHIEVED

STONE OBSTRUCTION ASSCOCIATED WITH INFECTIONS

RISK FOR PYONEPHROSIS, UROSEPSIS

SINGLE KIDNEY WITH OBSTRUCTION

BILATERAL OBSTRUCTIONS

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ACTIVE REMOVAL Modality
of stone in the KIDNEY

EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY

(ESWL)

PERCUTANEOUS REMOVAL - PERCUTANEOUS

NEPHROLITHOTRIPSY ( PCNL/PNL )

RETROGRADE REMOVAL OR RENAL STONES

OPEN SURGERY

LAPAROSCOPIC SURGERY

CHEMOLYTIC DISSOLUTION USING PERCUTANEOUS

IRRIGATION

(RIRS)

+
STAGHORN STONES
PNL

( monoterapi )

Kombinasi
ESWL

( monoterapi )

Operasi

terbuka

Kombinasi

ESWL

PNL dan ESWL

Operasi Terbuka dan

+
Management Patients with
STONE in the URETER

OBSERVATION AND MEDICAL EXPULSIVE THERAPY ( MET )

EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY

(ESWL)
( URS )

URETERO RENOSCOPY

ANTEGRADE REMOVAL OF URETERAL STONES

OPEN SURGERY

LAPAROSCOPIC SURGERY

CHEMOLYTIC DISSOLUTION USING PERCUTANEOUS

IRRIGATION

+
Management Patients with
STONE in the BLADDER
Vesicolitholapaxy
Vesicolithotripsy
Vesicolithotomy

Perkutan
Vesicolithotomy

Terbuka
ESWL

+
METABOLIC EVALUATION
and RECURRENCE
PREVENTION
After

stone passage, every patient

should be assigned to a low- or
high-risk group for stone formation
.

For

correct classification, two items

are mandatory:
reliable

stone analysis by infrared

spectroscopy or X-ray diffraction;
basic analysis.

+
General preventive
measures
Fluid intake (drinking advice)
Fluid

amount: 2.5-3.0 L/day

Circadian drinking
Neutral pH beverages
Diuresis: 2.0-2.5 L/day
Specific weight of urine: <
1010

+
General preventive
measures
Nutritional advice for a balanced
diet
Balanced

diet*
Rich in vegetable and fibre
Normal calcium content: 1-1.2 g/day
Limited NaCl content: 4-5 g/day
Limited animal protein content: 0.8-1.0
g/kg/day
* Avoid excessive consumption of vitamin supplements.

+
General preventive
measures
Lifestyle advice to normalise
general risk factors
BMI:

18-25 kg/m2 (target adult

value, not applicable to children)
Stress limitation measures
Adequate physical activity
Balancing

of excessive fluid loss

+
RESUME

DIAGNOSA ( Ax :, PF, Lab, Penunjang )

Treatment tergantung

Modalitas Terapi :

Cegah Rekurensi.

Low Risk

High Risk