Rifa Roazah

By the 19th century accounted for 80% of

urolithiasis in Europe
Some historical figures : King Leopold I of
Belgium, Napoleon Bonaparte, Emperor
Napoleon III, Peter the Great, Louis XIV,
George IV, Oliver Cromwell, Benjamin
Franklin, Chief Justice John Marshall, Sir
Francis Bacon, Sir Isaac Newton, the
physicians Harvey and Boerhaave, and the
anatomist Scarpa.
In the lower urinary tract, most calculi occur
in the bladder.
Vesical calculi can be classified as
migrant
primary idiopathic
secondary calculi
Calculi formed in the upper tracts, pass
into the bladder, and are retained there.
Most calculi <1 cm and in adults, are easily
passed per urethra.
Retained upper tract stones may grow to a
large size in the bladder

Form in children in the absence of
obstruction, local disease, neurologic
lesion, or known primary infection.
Remain common in infants and children of
lower socioeconomic background (ex : North
Africa)
Results from dietary and nutritional
deficiencies
Children in these areas are dependent on a
cereal-based diet (wheat flour, millet, and
rice) that is lacking in animal proteins,
especially cow's milk LOW PHOSPORUS

Leads to low urine phosphate excretion and
high peaks of ammonia excretion






Most commonly composed of ammonium acid
urate alone or in combination with calcium
oxalate, but many also contain calcium
phosphate.

Chronic dehydration,
excessive protein or
oxalate consumption,
high endogenous
oxalate production,
and deficiencies in
vitamins A, B
1
, and B
6

and magnesium

associated with stone
formation
Children younger than 10 years are typically
affected, with the peak incidence : 3 years
Male-to-female ratio 10:1
Common symptoms :
vague abdominal pain
hypogastric discomfort
interruption of the urinary stream
pulling and rubbing of the penis
Some children complain of dysuria, frequency,
suprapubic pain, and dribbling.
Small calculi may be passed with
hydration, antispasmodics, and analgesics,
but most cases will require surgical
intervention.
Usually solitary and rarely recur once
removed.
Predominantly a disease of adults and
accounts for approximately 5% of urinary
calculi in developed countries
Related to :
urinary stasis
recurrent urinary tract infection due to bladder
outlet obstruction or neurogenic bladder
dysfunction.
foreign bodies in the urinary tract
More than 75% of bladder calculi cases
Associated with outlet obstruction
Affect men older than 50 years and are most
often related to benign prostatic
hyperplasia
Calculi resulting from obstruction may be
composed of uric acid, calcium, or
magnesium ammonium phosphate if
infected.
Other causes of outlet obstruction :
urethral stricture
bladder neck contracture
neurogenic bladder dysfunction
in women, urogenital prolapse
Residual urine from outlet obstruction predisposes
to infection, and combined, these factors may result
in stone formation
Most commonly with Proteus. Organisms such as
Pseudomonas, Ureaplasma urealyticum, Providencia,
Klebsiella, Staphylococcus, and Mycoplasma are also
capable of producing bacterial urease.
The urease hydrolyzes urea, forming ammonium and
carbon dioxide, which increases urine pH. Alkaline
urine promotes supersaturation and precipitation of
crystals of magnesium ammonium phosphate.
Long-term bladder catheterization risk
for urinary infection and calculus formation.
Approximately 50% to 98% of catheter-
associated calculi are composed of
magnesium ammonium phosphate; the
remainder are a combination of calcium
oxalate and phosphate or pure calcium
phosphate
Patients managed with an indwelling urethral
or suprapubic catheter had a ninefold
increased risk for development of a bladder
stone compared with patients who were
catheter free and had continent bladder
control
The urinary tract is the occasional repository
for a wide array of foreign objects
These foreign bodies can be classified as :
self-induced
iatrogenic
migrant
Self-induced insertion may be the result of
psychological abnormalities
Calculi may develop on foreign objects in the
absence of infection
Stone formation is inhibited by dilution, diuresis,
and acidification of urine
Stone formation is enhanced with infection,
especially with urea-splitting organisms
Calculi may form around nearly any type of
suture.
Foley catheters act as foreign bodies;
encrustations may form around the tip or the
balloon of the catheter.
These encrustations may act as nidi for
further stone growth.
Bladder calculi from migrant foreign bodies
have been reported as complications of
urologic and nonurologic surgical
procedures.
Most bladder calculis are asymptomatic
and are found incidentally.
Patients with significant bladder outlet
obstruction may : initially present with
lower urinary tract symptoms or recurrent
(persistent) urinary tract infections, especially
with a urea-splitting organism.
Intermittent voiding with increase in terminal
dysuria caused by lodging at the bladder neck.
Painful voiding (varying quality and exacerbated
by exercise and sudden movement). The pain
may be referred to the tip of the penis, the
scrotum, or the perineum and on occasion to
the back or the hip.
Recumbent position may alleviate the
symptoms.
Hematuria
Plain radiographs may be missed because
of overlying bowel gas, soft tissue
shadowing, and the radiolucent quality of
some calculi.
Ultrasonography can be used to detect
radiolucent calculi but may be limited by
bowel gas.
CT Scan
Cystoscopy is the single most accurate
examination to document the presence of a
bladder calculus.
Cystoscopy assists in surgical planning by
identifying prostatic enlargement, urethral
stricture that may need correction before or
in conjunction with the treatment of the
stone.
The majority of bladder calculi are treated
endoscopically
The approach is influenced by :
patient's anatomy and comorbidities
stone size, location, and composition
previous stone treatment
risks and complications
In addition to removal of the calculi, treatment
should address predisposing factors such as bladder
outlet obstruction, urinary stasis, infection, and
foreign bodies to minimize recurrence.
Suby solution G or hemiacidrin dissolve
magnesium ammonium phosphate calculi.
Uric acid calculi oral sodium or potassium
citrate.
Dissolution for primary treatment of bladder
calculi is now rarely employed.
The bladder is filled with 100 to 150 mL of
normal saline through the catheter to improve
visualization.
After the calculus has been localized, the
bladder is drained, which minimizes stone
migration.
Multiple treatments of bladder calculi with SWL
may be required to achieve stone-free status
SWL may be considered for those who are unfit
for surgery because of comorbid medical
conditions or who refuse surgery.
Cystolitholapaxy is the crushing of the
calculus with irrigation of the fragments
from the bladder in a single operation.
Contraindications :
small-capacity bladders
multiple stones or calculi larger than 2 cm
hard stones
bladder calculi in children
small-caliber urethras
During the procedure, the bladder should be
filled with about 200 mL of irrigant.
The stone is then crushed manually, and the
procedure is repeated several times until
fragments can no longer be caught.
Energy pneumonik, electrohydraulic,
ultrasonic, laser
Indicated in pediatric patients with narrow
urethras and in patients with large stone
burdens or multiple calculi
Contraindications :
a history of bladder malignant disease
prior abdominal or pelvic surgeries
prior pelvic radiotherapy
active urinary or abdominal wall infection
pelvic prosthetic devices
The percutaneous puncture is positioned
above the symphysis or at a prior suprapubic
tube site
Success rates for percutaneous
cystolithotomy range from 85% to 100% with
various energy sources
Although rarely used today, open
cystolithotomy for the treatment of bladder
calculi is associated with a high success rate
Good for very large or hard stones
Other indications :
abnormal anatomy
failure of an endoscopic approach
concomitant open prostatectomy
Rifa Roazah
Urethral calculi represent less than 2% of all
urinary stone disease in the Western world
Urethral calculi in women are exceptionally
rare because of low rates of bladder calculi
and a short urethra that permits passage of
many smaller calculi.
Urethral calculi can be classified as either
native or migrant. Native urethral calculi form
de novo in association with abnormalities that
predispose to urinary stasis and infection.
Calculi may form proximal to strictures, in
congenital or acquired diverticula, with
chronic infection (especially with urea-
splitting organisms), with foreign bodies, in
schistosomiasis, and with use of hair-bearing
skin for urethroplasty. These calculi are
frequently composed of struvite, calcium
phosphate, or calcium carbonate.
Calculi in the female urethra are typically
associated with urethral diverticulum or
urethrocele
The majority of urethral calculi in men are
migrant, formed in the urinary bladder or
upper tract, whose passage has been
impeded in the urethra
Although stones smaller than 10 mm
should pass through the normal urethra,
areas of possible stone impaction are the
prostatic urethra, the bulb, the proximal
penile urethra, the fossa navicularis, and
the external meatus. A migrant stone may
become impacted at the site of a urethral
stricture.
Native urethral stones generally do not
cause acute symptoms because of their
slow development and growth.
Patients may present with a mass that has
gradually increased in size and hardness on
the undersurface of the penis or anterior
wall of the vagina, urethral discharge,
dyspareunia, irritative voiding symptoms,
and hematuria.
Adult men with urethral calculi may present
with acute retention or complaints of
frequency, dysuria, poor or interrupted urinary
stream, incomplete emptying, and dribbling
or incontinence. Pain caused by the stone may
be severe.
When the calculus is lodged in the posterior
urethra, the pain is referred to the perineum or
the rectum. When the calculus is lodged in the
anterior urethra, the pain may be localized at
the site of the impaction.
Rectal examination may detect stones in
the posterior urethra. Radiography can be
helpful but requires proper positioning of
the patient as urethral calculi are
frequently overlooked on plain films and
intravenous urograms.
Treatment is contingent on the size and
location of the calculus and condition of the
urethra.
The objective of treatment is relief of
obstruction and foreign body removal
without damaging the urethra and
periurethral tissues.
Urethroscopic lithotripsy and removal of
stone fragments is useful in almost any
situation.
Meatotomy may be used if the stone is
lodged in the fossa navicularis or the
external meatus.
A stone in the anterior urethra may be
treated with the judicial use of forceps.
On occasion, a small stone may sometimes
be gently massaged or milked outward, so
that it can be expelled.
When a stricture obstructs passage of a
stone, dilatation or internal urethrotomy
may be necessary before the manipulation.
Calculi in the posterior urethra can be
treated in situ or pushed back into the
bladder and treated as vesical calculi
Urologi Basuki
Urologi Smith
Urologi Campbell