CASE PRESENTATION

A. PATIENT IDENTITY
Name
: Mr. O
Age
: 58 years old
Sex
: Male
Address
: Luewie Gede
Religion
: Moslem
Marital Status
: Married
MR Number
: 873999
B. ANAMNESIS
Main Grievance
The patient involved when urinate

Historical of Present Disease

The patient came to the hospital Arjawinangun because he got involved when

urinate since 1 week ago. Not only involved, but the patient felt painful too when he
urinated. Both of the complaints had been feeling by the patient since 1 week ago. The
patient said that he never felt this complaint before, it was disturbed for him and because
both of the reasons he came to Arjawinangun Hospital to check his condition. The patient
said there is no another complaints such as vomiting and abdominal pain.
Historical of Past Disease
Hipertension (-)
Diabetes Melitus (-)
Historical of Family Disease
Hipertension (-)
Diabetes Melitus (-)
The patient said there was no one of his family member that has a disease like him

C. MEDICAL EXAMINATION
Present Status
General Condition
: Moderate
Awareness
: Composmantis
Blood Pressure
: 120/70
Pulse
: 73 x/minute
Breathing
: 17 x/minute
Temperature
: 36,5 C
General Status
Head
Form
: Normal, Simetrical
Hair
: Black Colour, No hair fall
Eye
: Anemic Conjungtival -/Icteric Schlera -/Light Refleks (+)
Isocor pupil right = left
: Normal form, cerumen (-), tympani membrane intac
: Normal form, No septum deviation, epitaction -/: Normal

Ear
Nose
Mouth
Neck
Enlargement lymph nodes (-)
Trachea in the middle
No mass
Thorax
Lungs - pulmonary
Inspection
: The chest shape is symmetrical both ofleft and right
Palpation
: Fremitus tactile and vocal symmetrical right and left,

Percussion
Auscultation

crepitus (-), tenderness (-), rebound tenderness (-)

: Sound of resonant in both lung fields
: Sound of vesicular and bronchial the entire lung field,

ronkhi -/-, wheezing -/Heart

Inspection
: Ictus cordis is not visible
Palpation
: Ictus cordis palpable on the left midclavicula ICS line 5
Percussion
: Upper limit ICS 3 linea parasternalis sinistra
Right limit ICS 4 linea sternalis dextra

Left limit ICS 5 linea midclavicula sinistra

Auscultation : Heart sound 1 2 pure regular, murmur (-), gallops (-)

Abdomen
2

Inspection
Palpation

back of abdominal left.

Percussion
: There was a whole field tympanic abdomen
Auscultation
: Bowel (+) Normal

: flat abdomen shape, supple, not visible skin disorders

: tenderness (-), rebound tenderness (-), feeling hurt on the

Ektremitas
o Superior
: Akral warm, Edema -/-, CTR < 2
o Inferior
: Akral wamt, Edema -/-, CTR < 2
Genitalia
: No abnormalities
Localist Status:
Inspection
Palpation

: there was no inflammatory reaction.

: the patient felt hurt when ballottement on the left abdominal palpation

was done.

INVESTIGATIONS
Laboratory Examination
Complete Blood
Leukocytes :6160/mm3
Red Blood Cell : 230000/mm3
Hb : 13,4 gr/dL
BT : 1
CT : 2 30
LED : 70 mm/hour
Ureum : 24,9 mg/dl
Creatinin : 1,49 mg/dl
Glucose : 144 mg/dl
E. DIAGNOSIS OF WORK
Uroterolithiasis Sinistra
F. DIFFERENTIAL DIAGNOSIS
G. MANAGEMENT PLAN
Non-medical (surgery) :
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a. Removal Stone
medical:

Infusion RL 20 GTT / min

Hypobach 2 x 1

lactar 2 x 1

H Prognosis
Quo ad vitam

: Ad Bonam

Quo ad functionam

: Ad Bonam

Quo ad sanactionam : Ad Bonam

LITERATURE REVIEW
BLADDER STONE OR VESICOLITHIASIS (DEFINITION, ETIOLOGY,DIAGNOSIS
AND MANAGEMENT)
CHAPTER I
INTRODUCTION
A. DEFINITION
Urolithiasis is a disease that is symptomatic of the formation of stones in the urinary tract.
Suspected urinary tract stone formation related to urine flow disorders, metabolic disorders,
urinary tract infection, dehydration, and other circumstances that remain unclear (idiopathic).
Epidemiologically, there are several factors that facilitate the occurrence of urinary tract stones at
someone. These factors are intrinsic factor which is the state that comes from one's body and
extrinsic factors that influence comes from the surrounding environment.

Intrinsic factors such as:

A. Hereditary (hereditary). The disease is thought to be derived from his parents.
2. Age. The disease is most often obtained at the age of 30-50 years.
3. Gender. The number of male patients are three times more than the number of female patients.
Several extrinsic factors such as:
A. Geography. In some areas show the incidence of urinary tract stones are higher than other
areas and became known as the stone belt (belt rocks), while the Bantu in South Africa found
almost no urinary tract stone disease.
2. Climate and temperature.
3. Water intake. Lack of water intake and high levels of calcium in mineral water consumption
can increase the incidence of urinary tract stones.
4. Diet. Many purine diet, oxalate, and calcium facilitate the occurrence of urinary tract stone
disease.
5. Job. The disease is often found in people who are sedentary or less pekerjannya activity or
sedentary life style.
B. THEORY OF THE FORMATION OF STONE TRACT.
The theory of the formation of stones:
A. The theory of the core (nucleus); crystals and foreign body is where the deposition of crystals
in the urine which have had a supersaturasi.
2. Matrix theory; organic matrix derived from serum or urine protein-protein offers the
possibility of precipitation of crystals.
3. The theory of crystallization inhibitors; some substance in the urine to inhibit the
crystallization, the low concentration or absence of this substance allows the crystallization.
C. Etiology TRACT STONES:
A. Idiopathic.
2. Disorders of urine flow.
- Phimosis.
- Stricture meatus.
- Hypertrophy of the prostate.
- Vesicoureteral reflux.
- Ureterokele.
- Constriction associated with ureteropelvik.
3. Metabolic disorders.
- Hyperparathyroidism.
- Hiperuresemia.
- Hypercalciuria.
4. Urinary tract infections by microorganisms that can make a urease (Proteus mirabilis).
5. Dehydration.
6. Foreign objects.
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7. Tissue death (necrosis papil).

8. Multifactorial.
- Children in developing countries.
- Patients multitrauma.
Theoretically can form stones in the entire urinary tract, especially in places that are
experiencing barriers to the flow of urine (urinary stasis), namely the system of renal calices or
jar. Congenital abnormalities in pelvikalises (uretero-pelvic stenosis), diverticular, chronic
obstructive infravesika as in benign prostate hyperplasia, stricture, and neurogenic bladder is a
condition that facilitates the formation of stones.
A rock composed of crystals composed of organic and inorganic materials dissolved in the urine.
The crystals remain in a metastable state (remains dissolved) in the urine in the absence of
particular circumstances which caused the precipitation of crystals. Precipitation of crystals held
together to form a rock core (nucleation) which would then hold the aggregation, and other
interesting material so that it becomes larger crystals. Although the size is large enough,
aggregate crystals are fragile and not quite able clogs up the urinary tract. For the aggregate
crystals stick to the urinary tract epithelium (shape retention crystals) and from other materials
deposited on aggregate to form stones that are large enough to block the urinary tract.
Metastable condition is influenced by temperature, pH, presence of colloids in the urine, the
concentration of solute in the urine, urine flow rate in the urinary tract, or the corpus alienum in
the urinary tract that acts as the core stone.
More than 80% of urinary tract stones composed of calcium stones, both of which bind with
oxalate or phosphate, forming calcium oxalate stones and calcium phosphate, while the rest
comes from uric acid stones, magnesium ammonium phosphate stones (infection stones), stone
xanthyn, cysteine stones, and other types of stone. Although the pathogenesis of stone formation
in the almost same, but the atmosphere inside the urinary tract that allows the formation of the
rock types are not the same. In this simple example uric acid stones form in acidic conditions,
while the magnesium ammonium phosphate stones form because the urine is alkaline.

D. COMPOSITION STONE
Urinary tract stones in general contain the following elements: calcium oxalate or potassium
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phosphate, uric acid, magnesium ammonium phosphate (MAP), xanthyn, and cystine, silicates,
from other compounds. Data regarding the content / composition of substances contained in
rocks is very important for prevention efforts against the possibility of stone residif.
Calcium stone
Stones of this type most often found, which is approximately 70-80% of all urinary tract stones.
The content of this type of rock composed of calcium oxalate, calcium phosphate, or mixtures of
the two elements.
Factor of calcium stones are:
A. Hiperkalsiuri, the levels of calcium in the urine is greater than mg/24jam 250-300. According
to Pak (1976) there are three kinds of causes of hiperkalsiuri, among others:
- Hiperkalsiuri absorptive occurring due to an increased absorption of calcium through the
intestines.
- Hiperkalsiuri occur because of impaired renal reabsorption of calcium through the ability of the
kidney tubules.
- Hiperkalsiuri resorptif is due to the increase in bone calcium resorption is the case with primary
hyperparathyroidism or parathyroid tumors.
2. Hiperoksaluri, the excretion of urinary oxalate in excess of 45 grams per day. This situation is
often found in patients with disorders of the intestine after undergoing intestinal surgery and
patients who consumed foods rich in oxalate, among which are: tea, instant coffee, soft drinks,
cocoa, strawberry, lemon, and green vegetables, especially spinach.
3. Hyperuricosuria, the levels of uric acid in urine in excess of 850 mg/24jam. Excessive uric
acid in the urine acts as a core rock / nidus for calcium oxalate stone formation. Source of uric
acid in the urine comes from the foods that contain lots of purine or derived from endogenous
metabolism.
4. Hipositraturia, in the urine reacts with the calcium citrate form of calcium citrate, thus
blocking the binding of calcium with oxalate or phosphate. This is possible because the binding
of calcium citrate is more soluble than calcium oxalate. Therefore, citrate can act as an inhibitor
of calcium stone formation. Hipofosfaturi can occur in renal tubule acidosis disease or
malabsorption syndrome, renal tubular acidosis, or the use of thiazide diuretics group in the long
term.
5. Hipomagnesuria, as well as the citrate, magnesium acts as an inhibitor of calcium stone
incidence, because the magnesium in the urine reacts with oxalate to magnesium oxalate thus
preventing the binding of calcium with oxalate. The most common cause is hipomagnesuria
inflammatory bowel disease (inflammatory bowel disease) followed by malabsorption disorders.
Uric acid stones
Uric acid stones is 5-10% of all urinary tract stones. Between 75-80% of uric acid stones
composed of uric acid and the remainder is a mixture of pure calcium oxalate. Uric acid stone
disease affects many patients with gout disease, myeloproliferative disease, patients receiving
anti-cancer therapy, and a lot of drug use among the sulfinpirazone urikosurik, thiazide, and
7

salicylate. Obesity, alcohol consumption, and high-protein diet have a greater opportunity to get
this disease.
Source of uric acid from purine-containing diet and endogenous metabolism in the body.
Degradation of purines in the body through inositat acid converted into hipoxanthyn. With the
help of xantyhn oxidase enzyme, hipoxanthyn which eventually turned into xanthyn converted
into uric acid. In mammals other than humans and dalmation, have enzymes that can alter
urikase uric acid into allantoin which is soluble in water. In humans because it does not have that
enzyme, uric acid is excreted into the urine in the form of free uric acid and urate salts are more
likely to bind to the sodium to form sodium urate. Sodium urate more soluble in water compared
with uric acid-free, making it impossible to hold a crystallization in the urine.
Relatively insoluble uric acid in the urine so that in certain circumstances is easy to form crystals
of uric acid, and subsequently form uric acid stones. Factors that led to the formation of uric acid
is; urine is too acidic (pH urine <6), with small amounts of urine volume (<2 liters / day) or
dehydration, hiperurikosuri or high uric acid levels.
Uric acid stone size ranged from small to large sizes so as to form staghorn stones that fill the
entire pelvikalises kidney. Not like a rock that looks kind of jagged calcium, uric acid stone is
smooth and rounded shape so it often came out spontaneously. Pure uric acid stones are
radiolucent, so that the examination of PIV appears as a shadow filling defect in the urinary tract
so often be distinguished by a blood clot, the formation of renal papillae necrosis, tumor or
fungal bezoar. On ultrasound examination gives an acoustic shadow (acoustic shadow).
To prevent recurrence of uric acid stones after treatment, is, drinking a lot, alkalanisasi urine to
maintain pH between 6.5 to 7, and keep not going to prevent the occurrence of hyperuricemia
hyperuricosuria. Every morning, patients are encouraged to check the pH of the urine with paper
nitrazin, and guarded so that no urine production less than 1500-2000 ml per day. Uric acid
levels examined periodically, and if there is hyperuricemia should be treated with drugs xanthyn
oxidase inhibitor, which is allpurinol.
E. EXAMINATION
Plain photo abdomen
Making a plain photo abdomen aims to look at the possibility of a radio opaque stones in the
urinary tract. Types of calcium oxalate stones and calcium phosphate is radio opaque and most
often found among the other stones, while the uric acid stone is non opaque (radio lusen).
INTRA PIELOGRAPHY VEINS (PIV)
This examination aims to assess the anatomy and renal function. In addition it can detect the
presence of PIV semi-opaque stone or non-opaque stone that can not be seen by plain photo
abdomen. If the PIV can not explain the state of the urinary system due to a decrease in renal
function, as a successor is pielografi retrograde examination.

ULTRASONOGRAPHY (USG)
Ultrasound may be performed if the patient does not undergo PIV, which is in the state; allergy to
contrast material, decreased renal physiology, and in women who are pregnant. Ultrasound
examinations can examine the stone in the kidney or bladder shown as echoic shadow,
hydronephrosis, renal pionefrosis or shrinkage.
F. MANAGEMENT
Stones that have caused problems in the urinary tract should be removed as soon as possible so
as not to cause more severe complications. Indications for therapeutic action in the urinary tract
stones if the stone has caused: obstruction, infection, or should be taken as an indication of the
social.
Obstruction due to urinary tract stones that have caused hidroureter or hydronephrosis and stone
that has been causing a urinary tract infection, should be released. Sometimes urinary tract stones
do not cause complications such as above, but suffered by a person for the job (eg stone suffered
by an aircraft pilot) have a high risk can lead to blockage of the urinary tract in question was at
the time of their profession, in which case the rock must be expelled from the urinary tract.
Stones can be removed by ESWL Medical solved through action endourology, laparoscopic
surgery or open surgery.
MEDICAL
Medical treatment intended to rock the size of less than 5 mm, because the stone is expected to
come out spontaneously. Given therapy aims to relieve pain, facilitate the flow of urine by
administering diuretikum, and drink a lot in order to push the stone out of the urinary tract.
ESWL (Extracorporeal Shockwave LITHOTRIPSY)
ESWL is a rock-breaking tool that was first introduced by Caussy in 1950. This tool can break up
kidney stones, stones proximal ureter, or bladder stones without invasive and without anesthesia.
Stone broken into small fragments that easily excreted through the urinary tract. Not infrequently
the rock fragments that induce a feeling of being out of colicky pain and cause hematuria.
ENDOUROLOGY
Endourology action is minimally invasive techniques to remove urinary tract stones are
composed of rock breaking, and then remove it from the urinary tract through a device that is
inserted directly into the urinary tract. The device is inserted through the urethra or through a
small incision in the skin (percutaneous). Stone-solving process can be done mechanically, by
means of hydraulic energy, the energy of sound waves, or with laser energy. Some of
endourology action are:
A. PNL (Percutaneous Nephro Litholapaxy), which issued the stone inside the kidney channel by
inserting an endoscope into the system calices instrument through an incision in the skin. Stone
is then removed or broken down into tiny fragments advance.
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2. Lithotripsy, which breaks the rock or stone bladder urethra by inserting a rock-breaking tool
(litotriptor) into the jar. Rock fragments removed by evakuator Ellik.
3. Ureteroskopi or uretero-renoskopi, which include peruretram ureteroskopi tool to see the state
of the ureter or renal system pielo-Calix. By using a particular energy, the stone inside the ureter
and the system can be broken down through the guidance pelvikalises ureteroskopi /
ureterorenoskopi this.
4. Dormia extraction, which issued a ureteric stone with Dormia basket menjaringnya through
the tool.
LAPAROSCOPIC SURGERY
Laparoscopic surgery to take urinary tract stones are currently being developed. This method is
most often used to take the ureter.
OPEN SURGERY
In the clinics that do not have adequate facilities for the action endourology, laparoscopy, or
ESWL, stone retrieval is performed through open surgery. Open surgery include: pielolitotomi or
nefrolitotomi to pick up stones in the bile duct, and for stones in the ureter ureterolitotomi. Not
infrequently the patient must undergo nefrektomi action or decision because the kidneys are not
functioning kidneys and contains pus (pionefrosis), korteksnya is very thin, or experiencing
shrinkage due to urinary tract stones that cause obstruction and chronic infection.
BLADDER STONE
Stone bladder or vesikolitiasis often occurs in patients suffering from micturition disorders or
there is a foreign object in bladder. Micturition disorders occur in patients with prostatic
hyperplasia, urethral strictures, bladder diverticular, or neurogenic bladder. Catheter attached to
bladder for a long time, the presence of other foreign objects that accidentally inserted into the
bladder is often a core for the formation of bladder stones. Besides bladder stones can be derived
from the kidney or ureter stones are dropped into a jar. In developing countries are still common
in endemic stone jars are often found in patients suffering children who are malnourished or
suffer from dehydration or diarrhea. Typical symptoms of bladder stones is a form of irritation
symptoms include: pain when urinating (dysuria) to stranguri, uneasy feeling when urinating,
and urinate all of a sudden stop and then smoothly return with changes in body position. Pain
during micturition is often perceived (Referred pain) on the tip of the penis, scrotum, perineum,
waist to toe. In children often complain of eneuresis nokturna, in addition to frequently pulling
his penis (in boys) or rub the vulva (the girls). Often the composition of bladder stones composed
of uric acid or struvit (if the cause is an infection), so it is not uncommon on a plain abdominal
examination did not appear as an opaque shadow in the pelvic cavity. In this case the PIV
investigation on cystogram phase gives a negative image. Ultrasound can detect radiolucent
stones in a bladder. Bladder stones can be solved by lithotripsi or if too large requires open
surgery (vesikolitotomi). It is no less important is to make corrections to the causes of urinary
stasis.
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REFFERENCE
Jong WD, Syamsuhidayat R.2002 Buku Ajar Ilmu Bedah edisi 3. EGC. Jakarta
Utama HSY 2012. BLADDER STONE OR VESICOLITHIASIS (DEFINITION,
ETIOLOGY,DIAGNOSIS AND MANAGEMENT). Available online at
http://www.dokterbedahherryyudha.com/2012//soft

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SURGERY CASE PRESENTATION

UROLITHIASIS SINISTRA

NAME: TEGUH SONI REKSA

1102009283
PRECEPTOR: dr.H.HERRY SETYA YUDHA UTAMA SP.B, MH.Kes. FINACS
196211061987101001

MEDICAL FACULTY OF YARSI UNIVERSITY

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