Introduction

Kidney stones are made in the tubules of the kidney, and can occupy the calix,
infundibulum, kidneys pelvic, and even the whole calix. Stones that fill the pyelum and
more than two renals calix sometimes are called staghom stone due to its resemblance
to deer antlers. Problems and obstruction predispose the formation of a renal stone.
Stones that are not too big are pushed down to the ureters due to the peristaltic force,
thus becoming ureter stones. The peristaltic force of the ureter than tries to flush them
down to the urinary vesicle. A smaller stone, less than 5 mm, usually can be excreted
spontaneously, while the bigger ones usually stays in the ureter and may cause
inflammation and chronic obstruction such as hidroureters or hidronefrosis. In
Indonesia, kidney stones are the most prevalent disease in many urology clinics. The
exact insidence and prevalence have not been measured although it is predicted that one
in 1000 men and one in 3000 women came with a first complain of kidney stone in the
last one year. Around 15% of the patients will experience reccurency in the next one
year, and 30% in 5 years.
The formation of urinary stones is thought to be linked with the disturbance of urinal
flow, metabolic compromises, urinary tract infections, dehydration, and other idiopathic
etiologies. There are several factors that ease the formation of such stone accroding to
epidemiologic studies: intrinsic factors, factors that came from someones body; and
extrinsic factors, or enivironmental factors. Intrinsic factors that have been known to
cause stones are hereditary factors, that is described as parent-child direct realtions, age
between 30 until 50 years old, and gender which has been shown that male are three
times more likely to form a kidneystone than woman. Extrinsic factors that are known
to be related with kidney stone are geographical factor, whereas several regions have
shown to have a higher insidence of kidney stones, thus is called the stone belt, while
Bantu, a region in South Africa, recorded a really low number of kidney stone
incidences. Other extrinsic factors include climate and temperature, low water
consumption, high level of minerals within the water, urin, oxalate, and calcium-rich
diet, and lifestyle, whom people who routinely sit and have less activities are at high
risk. inya penyakit batu saluran kemih. Pekerjaan, Penyakit ini sering dijumpai pada

orang yang pekerjaannya banyak duduk atau kurang aktivitas atau sedentary life.
(Purnomo, 2007).
The formation of kidney stone is influenced by several factors, according to the theories
that it was based on. The superaturation theory are based on the saturation of the
components of the stone that will predispose a crystalization process. At certain point,
the sedimented crystals will cause an agression that in turn, will transform into a stone.
Another theory, the matrix theory, is based on matrix, which is a mucoprotein that
consists of 65% protein, 10% hexose, 3-5 hexoamin, an 10% water, that cause the
adhesion of crystals and at the end will cause the formation of stone. The theory of
inhibitorless is a theory that centers on the existence of a substance that acts as a
inhibitor of the oversaturated calcium of phosphate. Phosphat mucopolysaccharide and
diphosphates are the inhibitor of crystal formation. Lacking this substance will cause
sedimentation. In Epsitaxy theory, the stones are formed from several components
simultaneously, on which one of the stone will be the core, and the others form the outer
layer. For example, the excresion of uric acid will promote the formation of calcium
stone with a core of uric acid. Lastly, the combination theory are theories that are
combined by the thories from the above.
The indications for therapy for urinary stones present if the stone itself cause
obstruction, infectionm or have to be taken because of some social reasons. Obstruction
because of the urinary stone that later on complicate into hydroureters or hydronefrosis,
or stones that are causing urinary tract infections, have to be removeed as soon as
possible. The stones can be removed by means of medicine, breaking it down with
ESWL, endourology procedure, laparascopic suergery, or open surgery.
Medication
Medications are meant for stones that are less than 5 mm, because it is expected
that the stone can be removed spontaneously. The medications are intended to
decrease the pain, ease the flow of urine by diabeticum and a lot of drinking so
that the stone will eventually came out.
ESWL (Extracorporeal Shockwave Lithotripsy). This device can break down
kidney stones, proximal ureter stones, or bladder stones with an invasive means

without anhestesic. The stone will be broken down into little fragments so that it
can be easily removed throug the urinary tract.
Endo urology procedures is a minimal invasive procedure for removing urinary
stones that consist of breaking down the stone and removing it out by devices that
is inserted directly into the urinaey tracts. Several endourology procedures are:
1. PNL (Percutaneous Nephro Lithloplaxy)
This method is done by doing incision at the skin in order to access the calixes
so that an endoscopic device can be inserted. The stone is then broken down
into small fragments and removed.
2. Lithotrypsy
The stone in the bladder and urethra is broken down and then evacuated by the
Ellik evacuator.
3. Urethroscopy or uretherorenoscopy
Inserting the uretheroscopy through the urethra in order to see the condiion of
the urether or the pyelocalix system of the kidney. By using certan energy, the
stone inside the urether or the pyelocalix system can be broken down by this
means.
4. Dormia extraction
This is a mean of evacuating the stone by bagging it using the Dormia bag.
Case Presentation
Chief complain Pain at the left side of the back
Recent History
Patient complains a left side back pain that is getting worse since 1 day ago before
admision. The pain comes and goes randomly and is not exacerbated by activities. The
pain spread to the abdomen. The urine is clear, and there is no pain during micturition.
There is no complain on defecating. There is no fever, nausea, vomitting, and bloating.
6 months before admission, patient felt left sided back pain, intermittent, spread to the
abdomen, and no pain during micturition or defecation. Frequent micturition and change
of urine color was denied. Passing stone during micturition was also denied. The patient
did not feel any unsatisfactory micturising. Bloating, nausea and vomitting was also
Patient also denied any history of lifting heavy things. Patient went to Myria Hospital
but felt there were no difference. The patient was then referred to the RSMH
Palembang.
Beforehand, the patient complained a similiar pain 6 years ago, that was intermittent in
frequency. Defecation was normal. There was also a complain of bloody urine.
Although there were no turbid urine or fishy odor. The patient said that he passed stones
during micturition. Everytime the patient felt pain, he went to the Puskemas. The pain,
3

although it was gone once, was never actually diminished. All of the physical
examination were considered normal. At the sinistre costovertebrae region, there was a
knock pain. m batas normal. Pada satus lokalis regio costovertebre angel didapatkan
nyeri ketok CVA sinistra (+)

Discussion
From the case above, Mr Sutrisno, 54 years old came to the RSMH because of left sided
back pain that is spread to the abdomen and sometimes to the lower abdomen, and is
intermittent in frequency. From the anamnesis it was found that the complain was
present since 6 years ago. The pain was getting worse especially since 6 months ago
before admission. There was some organs that can cause right sided back pain such as
muscle, vertebrae, nerver (hernia nucleus pulposus), kidnet, and ureter. The pain at the
back or colic (flank pain) can be caused by kidney stone, intestinal distention, gall
bladder distention, or appendistis. The patients does not have any pain during
micturition, bloody urine, and the urine was clear. Thus, no malignancy is indicated.
Defecation is normal. There were no fever, nausea, or vomitting.
According to physical examination

the vital sign was withini normal limit, the

conjunctiva was not anemic, and the sclera was not icteric. On the inspection of CVA
and suprapubic reigion there was no deformity, and on the genitalia there was no bloody
discharge. There was a positive left sided knock pain on the CVA region. On the
physical examination of left kidney there was bulging, negative murphy sign, positive
ballotement, that indicatie the presence of the enlargement of a kidney (hydronefrosis).
On the local examination there was push and tap painon the CVA region, that supports
the hypothesis that the pain is orginated from the kidney or ureter.
On the routine blood laboratory examination there was a decrease of hematocrit. This is
probably caused by the depletion of hormone that stimulates the formation of
hemoglobin and erythropoietin. The depletions showed that a compromise on the
function of the kidney. At the leucocyte count, there was a decrease of rod neutrophil.

Supporting examinations were done. Using a USG, it is shown that the urinary tract and
the bladder was normal. The shape and size of the right kidney was normal, exogenity
was not increased, corticomedullary border was normal, no cortical thinning, no stone,
and the pyelocalix system was not widened. Instead, at the left kidney it was found that
there were multiple stone on the lower pole with a size of 1,55 cm. It is confirmed that
cause of the patients complain was stones on the ureter. In order to find out the renal
function and the stones size, a BNO IVP was done. The result was stone at the distal of
left ureter. The function of the kidney was normal, but there is a hydronephrosis grade
II.
From the anamnesis, physical examination, and supproting examination, then the patient
is then diagnosed with uretherolithiasis sinistra. Seeing the hydronephrosis and the size
of the stone then it is planned to do the URS.
The prognosis for this patient, in term vitam is dubia ad bonam, and in term of
functionam is also dubia ad bonam.