TUTORIAL KLINIK

BATU SALURAN KEMIH

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Epidemiology of Renal Canaliculi
Stone disease typically affects adult men
more commonly than adult women.
Stone occurrence is relatively uncommon
before age 20 but peaks in incidence in the
fourth to sixth decades of life (Marshall et al,
1975; Johnson et al, 1979; Hiatt et al, 1982).
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Among U.S. men, Soucie and colleagues
(1994) found the highest prevalence of stone
disease in whites, followed by Hispanics,
Asians, and African-Americans,who had
prevalences of 70%, 63%, and 44% of whites,
respectively.
a higher prevalence of stone disease is found
in hot, arid, or dry climates such as the
mountains, desert, or tropical areas.
3
 Heat exposure and dehydration constitute occupational
risk factors for stone disease as well. Those exposed to
high temperatures exhibited lower urine volumes and pH,
higher uric acid levels, and higher urine specific gravity,
leading to higher urinary saturation of uric acid.

Subjects with higher BMI excreted more urinary oxalate,

uric acid, sodium, and phosphorus than thosewith lower
BMI. Furthermore, similar to other studies, urinary
supersaturation of uric acid increased with BMI. It has
been suggested that the association of obesity with
calcium oxalate stone formation is primarily due to
increased excretion of promoters of stone
formation(Siener et al, 2004; Negri et al, 2007)

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 Urinary Stone
- Urinary stones are polycrystalline aggregates composed of
varying amounts of crystalloid and organic matrix.
- Stone formation requires supersaturated urine.
- Supersaturation depends on urinary pH, ionic strength,
solute concentration, and complexation.

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 urinary pH, ionic
strength, solute
concentration, and
complexation

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A. Crystal Component
• Stones are composed primarily of a crystalline component.
• Multiple steps are involved in crystal formation, including,
nucleation, growth, and aggregation.

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B. Matrix Component
• The amount of the noncrystalline, matrix component of urinary stones varies with
stone type, commonly ranging from 2% to 10% by weight.
• It is composed predominantly of protein, with small amounts of hexose and
hexosamine
• On plain abdominal radiographs, matrix calculi are usually radiolucent and can be
confused with other filling defects, including blood clots, upper-tract tumors, and
fungal bezoars.
• Noncontrast computed tomography (CT) reveals calcifications and can help to
confirm the diagnosis.

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URINARY IONS
• Calcium
• Oxalate
• Phosphate
• Uric Acid  Uric acid is the by-product of
purine metabolism. Other defects in purine
metabolism may result in urinary stone disease
Pure uric acid crystals and calculi are relatively
radiolucent and may not be identified on plain
abdominal films.They are visible on
noncontrast CT images and are suggestive
when found to have low Hounsfield units (HU).
• Sodium - Sulfate
• Citrate - Other Urinary Stone Inhibitors
• Magnesium
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 URINARY NON IONS
• Struvite  Struvite stones are composed of magnesium,
ammonium, and phosphate (MAP). They are found most
commonly in women and may recur rapidly. They frequently
present as renal staghorn configured calculi (branched with
stones occupying the renal pelvis and at least to renal
infundibuli) and rarely present as obstructing ureteral stones
except after surgical intervention (Figure 17–5).
• Struvite stones are infection stones associated with urea-
splitting organisms, including Proteus, Pseudomonas,
Providencia, Klebsiella, Staphylococci, and Mycoplasma.
• The urinary pH of a patient with a MAP stone rarely is <7.2
(normal urinary pH is 5.85). It is only at this elevated urinary
pH (>7.19) that MAP crystals precipitate.
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• Cystine
• Xanthine  Xanthine stones are secondary to a congenital deficiency of
xanthine dehydrogenase. This enzyme normally catalyzes the oxidation of
hypoxanthine to xanthine and of xanthine to uric acid.
• Indinavir
• Rare

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 • A majority of kidney stones are calcium stones, with calcium
oxalate (CaOx) and calcium phosphate (CaP) accounting for
approximately 80% of all of these stones, uric acid (UA)
Kidney stones about 9%, and struvite (magnesium ammonium phosphate
hexahydrate, from infection by bacteria that possess the
enzyme urease) approximately 10%, leaving only 1% for all
the rest (cystine, drug stones, ammonium acid urate)

staghorn Non-staghorn

calyceal or pelvic in
(filling numerous location, while ureteral
major and minor stones are defined as
calices proximal, middle or
distal.

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Symptoms and Signs at Presentation
• Upper-tract urinary stones frequently cause pain when passing down the
ureter. The character of the pain depends on the location. Calculi small
enough to venture down the ureter usually have difficulty passing through
the ureteropelvic junction, or entering the bladder at the ureterovesical
junction. More than 60% of patients presenting with ureteral colic will have
stones within 3 cm of the ureterovesical junction.

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Symptoms and Signs at Presentation
A. Pain
• Renal colic and noncolicky renal pain are the two types of pain originating from the
kidney. Renal colic usually is caused by stretching of the collecting system or ureter,
whereas noncolicky renal pain is caused by distention of the renal capsule.
• Renal colic does not always wax and wane or come in waves like intestinal or biliary
colic but may be relatively constant. Renal colic implies an intraluminal origin. Patients
with renal calculi have pain primarily due to urinary obstruction.
• Local mechanisms such as inflammation, edema, hyperperistalsis, and mucosal
irritation may contribute to the perception of pain in patients with renal calculi. In the
ureter, however, local pain is referred to the distribution of the ilioinguinal nerve and
the genital branch of the genitofemoral nerve, whereas pain from obstruction is
referred to the same areas as for collecting system calculi (flank and costovertebral
angle), thereby allowing discrimination.
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 Radiation of pain with various types of ureteral stone
Mid ureteral stone. Same as described earlier but with more
pain in the lower abdominal quadrant

Low ureteral stone. Same as described

earlier, with pain radiating into
bladder,vulva, or scrotum. The scrotal wall is
hyperesthetic. Testicular sensitivity is
absent. When the stone approaches the
bladder, urgency and frequency with
burning on urination develop as a result of
inflammation of the bladder wall around the
ureteral orifice.

Ureteropelvic stone. Severe costovertebral angle pain from

capsular and pelvic distention; acute renal and urethral pain
from hyperperistalsis of smooth muscle of calyces, pelvis,
and ureter, with pain radiating along the course of the
ureter (and into the testicle, since the nerve supply to the
kidney and testis is the same). The testis is hypersensitive.

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• The symptoms of acute renal colic depend on the
location of the calculus; several regions may be
involved: renal calyx, renal pelvis, upper and mid
ureter, and distal ureter. An orderly progression of
symptoms as a stone moves down the urinary tract
is the exception.

1. Renal calyx
• Stones or other objects in calyces or caliceal
diverticula may cause obstruction and renal colic. In
general, nonobstructing stones cause pain only
periodically, owing to intermittent obstruction. The
pain is a deep, dull ache in the flank or back that can
vary in intensity from severe to mild. The pain may
be exacerbated after consumption of large amounts
of fluid.

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• 2. Renal pelvis—Stones in the renal pelvis >1 cm in
diameter commonly obstruct the ureteropelvic
junction, generally causing severe pain in the
costovertebral angle, just lateral to the
sacrospinalis muscle and just below the 12th rib.
• This pain may vary from dull to excruciatingly sharp
and is usually constant, boring, and difficult to
ignore.
• It often radiates to the flank and also anteriorly to
the upper ipsilateral abdominal quadrant.

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• It may be confused with biliary colic or cholecystitis if on
the right side and with gastritis, acute pancreatitis, or
peptic ulcer disease if on the left, especially if the
patient has associated anorexia, nausea, or emesis.
• Partial or complete staghorn configured calculi that are
present in the renal pelvis are not necessarily
obstructive. In the absence of obstruction, these
patients often have surprisingly few symptoms such as
flank or back pain.
• Recurrent urinary tract infections frequently culminate
in radiographic evaluation with the discovery of a large
calculus.
• If untreated, these “silent” staghorn calculi can often
lead to significant morbidity, including renal
deterioration, infectious complications, or both.

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• 3. Upper and mid-ureter—Stones or other objects in the
upper or mid ureter often cause severe, sharp back
(costovertebral angle) or flank pain.
• The pain may be more severe and intermittent if the stone is
progressing down the ureter and causing intermittent
obstruction. Pain associated with ureteral calculi often projects
to corresponding dermatomal and spinal nerve root
innervation regions.
• Midureteral calculi tend to cause pain that radiates caudally
and anteriorly toward the mid and lower abdomen in a curved,
band-like fashion. This band initially parallels the lower costal
margin but deviates caudad toward the bony pelvis and
inguinal ligament. The pain may mimic acute appendicitis if on
the right or acute diverticulitis if on the left side, especially if
concurrent gastrointestinal symptoms are present.

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• 4. Distal ureter—Calculi in the lower ureter often cause pain
that radiates to the groin or testicle in males and the labia
majora in females.
• This referred pain is often generated from the ilioinguinal or
genital branch of the genitofemoral nerves.
• Diagnosis may be confused with testicular torsion or
epididymitis.
• Stones in the intramural ureter may mimic cystitis, urethritis,
or prostatitis by causing suprapubic pain, urinary frequency
and urgency, dysuria, stranguria, or gross hematuria. Bowel
symptoms are not uncommon.
• In women, the diagnosis may be confused with menstrual
pain, pelvic inflammatory disease, and ruptured or twisted
ovarian cysts. This pain pattern is likely due to the similar
innervation of the intramural ureter and bladder.

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• B. Hematuria
A complete urinalysis helps to confirm the diagnosis of a urinary stone by
assessing for hematuria and crystalluria and documenting urinary pH.
Patients frequently admit to intermitten gross hematuria or occasional tea-
colored urine (old blood).
Most patients will have at least microhematuria. Rarely (in 10–15% of cases),
complete ureteral obstruction presents without microhematuria.

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• C. Infection
• Magnesium ammonium phosphate (struvite) stones are
synonymous with infection stones.
• They are commonly associated with Proteus, Pseudomonas,
Providencia, Klebsiella, and taphylococcus infection. Calcium
phosphate stones are the second variety of stones associated
with infections.
• Calcium phosphate stones with a urine pH <6.4 are frequently
referred to as brushite stones, whereas infectious apatite
stones have a urinary pH >6.4.
• All stones, however, may be associated with infections
secondary to obstruction and stasis proximal to the offending
calculus.
• 1. Pyonephrosis
• 2. Xanthogranulomatous pyelonephritis
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• D. Associated Fever
The association of urinary stones with fever is a relative medical
emergency. Signs of clinical sepsis are variable and include fever,
tachycardia, hypotension, and cutaneous vasodilation. Fever
associated with urinary tract obstruction requires prompt
decompression

• E. Nausea and Vomiting

Upper-tract obstruction is frequently associated with nausea
and vomiting.

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A. Differential Diagnosis

Urinary stones can mimic other retroperitoneal and peritoneal pathologic states. A full
differential diagnosis of the acute abdomen should be made, including acute appendicitis,
ectopic and unrecognized pregnancies, ovarian pathologic conditions including twisted
ovarian cysts, diverticular disease, bowel obstruction, biliary stones with and without
obstruction, peptic ulcer disease, acute renal artery embolism, and abdominal aortic
aneurysm—to mention a few.

“Peritoneal signs should be sought during physical examination”

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B. History
A proper evaluation requires a thorough medical history. The
nature of the pain should be evaluated :
- including its onset;
- character;
- potential radiation;
- activities that exacerbate or ease the pain;
- associated nausea, vomiting,
- or gross hematuria;
- and a history of similar pain. Patients with previous stones
frequently have had similar types of pain in the past, but not
always.

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C. Risk Factors
• Crystalluria is a risk factor for stones. Stone formers,
especially those with calcium oxalate stones,
1. Crystalluria frequently excrete more calcium oxalate crystals, and
those crystals are larger than normal (>12 μm).

2.
• Renal stones are more common in affluent,
Socioeconomic industrialized countries
factors
• When diets containing minimal fat and protein resulted in a
decreased incidence of stones. Vegetarians may have a decreased
incidence of urinary stones. High sodium intake is associated with
3. Diet increased urinary sodium, calcium, and pH and a decreased
excretion of citrate; this increas urinary stones. Fluid intake and
urine output may have an effect on urinary stone disease. The
average daily urinary output in stone formers is 1.6 L/d
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 • Physicians and other white-collar workers have an increased incidence of stones
compared with manual laborers. Physical activity may agitate urine and dislodge
4. Occupation crystal aggregates. Individuals exposed to high temperatures may develop higher
concentrations of solutes owing to dehydration, which may have an impact on
the incidence of stones.

• Hot climates usually expose people to more ultraviolet light, increasing

5. Climate vitamin D3 production. Increased calcium and oxalate excretion has
been correlated with increased exposure time to sunlight

6. Family • A family history of urinary stones is associated with an increased

incidence of renal calculi. Large studies of identical twins have found
history that >50% of stones have a significant genetic component.

• The antihypertensive medication : Dyazide,

• Antacids
7. Medications • Carbonic anhydrase inhibitors
• Protease inhibitors
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• D. Physical Examination
The patient presenting with acute renal colic typically is in
- severe pain,
- often attempting to find relief in multiple, frequently bizarre,
positions.

“This fact helps differentiate patients with this condition from

those with peritonitis, who are afraid to move”.

- Systemic components of renal colic may be obvious, with

tachycardia, sweating, and nausea often prominent
- Costovertebral angle tenderness may be apparent
- An abdominal mass may be palpable in patients with long-
standing obstructive urinary calculi and severe hydronephrosis.
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• A thorough abdominal examination should exclude other
causes of abdominal pain. Abdominal tumors, abdominal
aortic aneurysms, herniated lumbar disks, and pregnancy may
mimic renal colic.
• Referred pain may be similar owing to common afferent neural
pathways.
• Intestinal ileus may be associated with renal colic or other
intraperitoneal or retroperitoneal processes.
• Incarcerated inguinal hernias, epididymitis, orchitis, and
female pelvic pathologic states may mimic urinary stone
disease. A rectal examination helps exclude other pathologic
conditions.

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 E. Radiologic Investigations
1. Computed tomography
• Noncontrast spiral CT scans are now the imaging modality of choice in patients
presenting with acute renal colic.
• It is rapid and is now less expensive than an intravenous pyelogram (IVP). It
images other peritoneal and retroperitoneal structures and helps when the
diagnosis is uncertain.
• Uric acid stones are visualized no differently from calcium oxalate stones.
• Matrix calculi have adequate amounts of calcium to be visualized easily by CT
scan. HU can help predict stone type and hardness.
• The increased use of CT scans has also increased the radiation exposure to stone
patients, especially those with recurrent disease.
• “CT scans should be used when the diagnosis is in doubt and
should not be routinely utilized for diagnosis or surveillance”
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2. Intravenous pyelography
• An IVP can simultaneously document nephrolithiasis and
upper-tract anatomy. It is rarely used today with the
widespread availability of CT scan and ultrasound.
3. Tomography
• Renal tomography is useful to identify calculi in the kidney
when oblique views are not helpful. It visualizes the kidney in a
coronal plane at a set distance from the top of the x-ray table.
4. KUB films and directed ultrasonography
• A KUB film and renal ultrasound may be as effective as an IVP
or CT scan in establishing a diagnosis. The ultrasound
examination should be directed by notation of suspicious areas
seen on a KUB film; it is, however, operator dependent. The
distal ureter is easily visualized through the acoustic window of
a full bladder. Edema and small calculi missed on an IVP can be
appreciated with such studies. New studies comparing CT
versus ultrasound for the acute diagnosis of urinary stones is
Yourunderway.
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5. Retrograde pyelography
• Retrograde pyelography occasionally is required to delineate
upper-tract anatomy and localize small or radiolucent
offending calculi.
6. Magnetic resonance imaging
• Magnetic resonance imaging is a poor study to document
urinary stone disease.
7. Nuclear scintigraphy
• Nuclear scintigraphic imaging of stones has recently been
appreciated. Bisphosphonate markers can identify even small
calculi that are difficult to appreciate on a conventional KUB
film

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 Intervention
A. Conservative Observation
• Most ureteral calculi pass and do not require intervention. Spontaneous
passage depends on stone size, shape, location, and associated ureteral
edema
• Ureteral calculi 4–5 mm in size have a 40–50% chance of spontaneous
passage. In contrast, calculi >6 mm have a >15% chance of spontaneous
passage.
• An alpha-blocker, nonsteroidal anti-inflammatory medications with or
without low-dose steroids is now becoming standard care to optimize
spontaneous ureteral stone passage
• Ureteral calculi discovered in the distal ureter at the time of presentation
have a 50% chance of spontaneous passage, in contrast to a 25% and 10%
chance in the mid and proximal ureter, respectively.

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B. Dissolution Agents
• The effectiveness of dissolution agents depends on
stone surface area, stone type, volume of irrigant, and
mode of delivery. Oral alkalinizing agents include
sodium or potassium bicarbonate and potassium
citrate. Extra care should be employed in patients
susceptible to congestive heart failure or renal failure.
Struvite stone dissolution requires acidification and
may be achieved successfully with Suby’s G solution
and hemiacidrin (Renacidin).
C. Relief of Obstruction
• Retrograde pyelography to define upper-tract anatomy
is logically followed by retrograde placement of a
double-J ureteral stent.
D. Extracorporeal Shock Wave Lithotripsy
• Extracorporeal SWL has revolutionized the treatment
of urinary stones. The concept of using shock waves to
fragment stones was noted in the 1950s inYour
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E. Ureteroscopic Stone Extraction
• Ureteroscopic stone extraction is highly efficacious for lower
ureteral calculi. Complication rates are rare. Calculi that
measure <6–8 mm are frequently removed intact. Nitinol
baskets are less traumatic than older round or flat-wired stone
baskets. Excessive force with any instrument in the ureter may
result in ureteral injury.
F. Percutaneous Nephrolithotomy
• Percutaneous removal of renal and proximal ureteral calculi is
the treatment of choice for large (>2.5 cm) calculi; those
resistant to SWL; select lower pole calyceal stones with a
narrow, long infundibulum and an acute infundibulopelvic
angle; and instances with evidence of obstruction; the method
can rapidly establish a stone-free status.

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G. Open Stone Surgery
• Open stone surgery is the historic way to remove calculi, yet it
is rarely used today. The morbidity of the incision, the
possibility of retained stone fragments, and the ease and
success of less invasive techniques have made these
procedures rare.
H. Other Renal Procedures
• Partial nephrectomy is appropriate with a large stone burden
in a renal pole with marked parenchymal thinning
I. Ureterolithotomy
• Long-standing ureteral calculi—those inaccessible with
endoscopy and those resistant to SWL—can be extracted with
an ureterolithotomy

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 Prevention
• In general, 50% of patients experience recurrent urinary stones within 5 years
without prophylactic intervention. Appropriate education and preventive measures
are best instituted with a motivated patient after spontaneous stone passage or
surgical stone removal.
A. Metabolic Evaluation
A systematic metabolic evaluation should be instituted after a patient has
recovered from urinary stone intervention or spontaneous stone passage. Stone
analysis should be obtained to help direct the workup. An initial 24-hour urine
collection for calcium stone formers should include tests for calcium, uric acid,
oxalate, citrate, phosphate, sulfate, sodium, volume, and pH. Baseline serum
levels for blood urea nitrogen, creatinine, calcium (with or without
parathyroid hormone), phosphorous, and uric acid are appropriate.

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B. Oral Medications
1. Alkalinizing pH agents
• Potassium citrate is an oral agent that elevates urinary pH effectively by
0.7–0.8 pH units. Typical dosing is 60 mEq in three or four divided doses
daily. Potassium citrat also may be used effectively to treat uric acid lithiasis
and nonsevere forms of hyperuricosuric calcium nephrolithiasis.
2. Gastrointestinal absorption inhibitor
• Cellulose phosphate binds calcium in the gut and thereby inhibits
calcium absorption and urinary excretion and is appropriate for patients
with type 1 absorptive hypercalciuria

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3. Phosphate supplementation
Renal phosphate leak is best treated by replacing phosphate.
4. Diuretics
Thiazides can correct the renal calcium leak associated with renal
hypercalciuria. A starting dose of 25 mg may be titrated based on urinary
calcium levels.
5. Calcium supplementation
6. Urease inhibitor
Allopurinol is used to treat hyperuricosuric calcium nephrolithiasis with
or without hyperuricemia.
7. Urease inhibitor
Acetohydroxamic acid is an effective adjunctive treatment in those with
chronic urea-splitting urinary tract infections associated with struvite
stones
8. Prevention of cystine calculi
Conservative measures, including massive fluid intake and urinary
alkalinization, are frequently inadequate to control cystine stone
formation.

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BLADDER STONES
Bladder (vesical) calculi are stones or calcified materials that are
present in the bladder (or in a bladder substitute that functions
as a urinary reservoir).

They are usually associated with urinary stasis but can form in
healthy individuals without evidence of anatomic defects,
strictures, infections, or foreign bodies.

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• Bladder calculi usually are a manifestation of an underlying pathologic condition, including
voiding dysfunction or a foreign body.

urethral stricture
Foley catheters and
benign prostatic
forgotten double-J
hyperplasia
ureteral catheters can
bladder neck contracture
serve as nidi for stones
or flaccid or spastic
neurogenic bladder

static urine

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• Patients present with irritative voiding symptoms, intermittent
urinary stream, urinary tract infections, hematuria, or pelvic
pain. Ultrasound of the bladder identifies the stone with its
characteristic postacoustic shadowing. The stone moves with
changing body position.

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 Figure 17–23. A: Plain abdominal radiograph demonstrating
two bladder calculi. B: Gross picture of removed bladder
calculi. Note the characteristic shape of jackstones typically
composed of uric acid.

Figure 17–24. A: Scout abdominal radiograph demonstrating

extraosseous calcification in the region of the bladder.
B: Intravenous pyelogram demonstrates stone to be within a
ureterocele.

Bladder stones can be solitary or

numerous (Figure 17–23).

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Differential diagnosis
The differential diagnosis for mobile filling defects includes the following:
• Clot
• Fungal ball
• Papillary urothelial carcinoma on a stalk

The differential diagnosis for nonmobile filling defects includes the following:
• Urothelial carcinoma
• Clot
• Calculus

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PEMERIKSAAN PENUNJANG
1. Urinalysis is usually inexpensive and rapid and provides
useful information in this setting. On laboratory studies,
less specific signs of vesical calculi include the following:
• Microscopic or gross hematuria
• Pyuria
• Bacteriuria
• Crystalluria
• Urine cultures positive for urea-splitting organisms

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2. Radioghrapy. The initial imaging study of choice is plain radiography of the
kidneys, ureters, and bladder (KUB), which is the least expensive and easiest
radiologic test to obtain. If the clinical suspicion remains high and the initial KUB
reveals no stones, the next step is bladder ultrasonography, which may be able to
differentiate a calculus from tumor or clot.
3. IVP demonstrates the stone as a filling defect in the bladder.

Abdominopelvic planar radiography is commonly used to identify radiopaque

bladder stones. However, calculi, which are composed predominantly of uric
acid, are radiolucent and, unless coated with calcium, are more difficult to
visualize on radiographs. Cystoscopy, noncontrast computed tomography
(CT), and ultrasonography are other diagnostic methods commonly used to
confirm the presence of bladder calculi.

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Multiple laminated bladder calculi in patient with Large calculus visible on plain film of
neurogenic bladder intravenous pyelogram performed for
hematuria

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4. Cystoscopy remains the most commonly used test for confirming the presence of
bladder stones and planning treatment. This procedure allows the examiner to
visualize the stones and assess their number, size, and position (see the images
below). Additionally, examination of the urethra, prostate, bladder wall, and ureteral
orifices allows identification of strictures, prostatic obstruction, bladder diverticula,
and bladder tumors.

Bladder stone accretion on matrix. Bladder stone accretion on

Patient had history of urinary tract
infections and presented with
Endoscopic view of spiculated "jack" stone irritative voiding symptoms and
with erythematous bladder mucosa in microscopic hematuria.
background
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matrix. Patient had history of
urinary tract infections and
presented with irritative voiding
symptoms and microscopic
hematuria
Pharmacologic Stone Dissolution
• The only potentially effective medical treatment for bladder
calculi is urinary alkalization for the dissolution of uric acid
stones. Stone dissolution may be possible if the urinary pH
can be raised to 6.5 or higher. Potassium citrate 60 mEq/day
is the treatment of choice. However, overly aggressive
alkalization may lead to calcium phosphate deposits on the
stone surface, making further medical therapy ineffective.
• Renacidin can be used to dissolve phosphate or struvite
calculi, but treatment is slow and invasive because it must be
used in conjunction with indwelling irrigating catheters.
Patients must also be monitored closely for signs of sepsis or
hypermagnesemia.

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Surgical Fragmentation and Removal
• Currently, 3 different surgical approaches to this problem are
used:
• Transurethral cystolitholapaxy
In transurethral cystolitholapaxy, cystoscopy is performed to
visualize the stone, an energy source is used to fragment it, and
the fragments are then removed through the cystoscope
• Percutaneous suprapubic cystolitholapaxy
In percutaneous suprapubic cystolitholapaxy (which now is often
the primary approach in the pediatric population), the
percutaneous route allows the use of shorter- and larger-
diameter endoscopic equipment (usually with an ultrasonic
lithotripter), thereby permitting rapid fragmentation and
evacuation of calculi.

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• Open suprapubic cystotomy
In open suprapubic cystotomy, stones are not fragmented but
are removed intact.
The advantages of suprapubic cystolithotomy include rapidity,
easy removal of several calculi in a single procedure, the ability
to extract calculi that are adherent to bladder mucosa, and the
ability to remove large stones that are too hard or dense to
fragment expeditiously via transurethral or percutaneous
techniques. The major disadvantages include postoperative pain,
longer hospital stay, and longer bladder catheterization times.

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URETHRAL STONES
• Urethral calculi in males are almost always secondary to stone
disease elsewhere (bladder or kidneys), these are called
"migrant calculi"
• Primary stone formation within the urethra itself is very rare,
but can be seen if stricture or urethral diverticulum is present
• Large urethral calculi may lodge at the point of urethral
narrowing such as the membranous urethra
• Most urethral stones in men present in the prostatic or bulbar
regions and are solitary.
• Symptoms are similar to bladder calculi—intermittent urinary
stream, terminal hematuria, and infection. The stones may
present with dribbling or during acute urinary retention. Pain
may be severe and, in men, may radiate to the tip of the
penis.
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• Imaging
Although rare, the case highlights the need to specifically
include the portion of urethra in abdominal radiograph
performed to evaluate for stone disease and to actively search
for stone in this region
On CT, urethral stone can easily be overlooked either
because it is not imaged (the urethra not commonly included in
a stone protocol CT) or missed by the reader

• Treatment:
Distal stones may be grabbed by stone forceps and
An abdominal radiograph shows an
extracted via urethral meatus (requiring general anesthesia) or oval calcification (arrow) in the
urethrolithotomy. Proximal stones may be pushed back into the midline below the pubic symphysis
bladder endoscopically, then extracted like a bladder stone in a male patient with multiple
small right renal calculi
(arrowhead).

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