HYDRONEPHROSIS SINISTRA ET CAUSA PARTIAL STAGHORN CALCULI OBSTRUCTION SINISTRA

Devyana E.Taslim 1, Marta Hendry 2

1Clinical Senior Cleckship, School of Medicine, Medical Faculty of Sriwijaya University, Dr.Mohammad Hoesin General Hospital, Palembang2Department of Urology, School of Medicine, Medical Faculty of Sriwijaya University, Dr.Mohammad Hoesin General Hospital, Palembang

Background

Obstruction is one of the most important

abnormalities of the urinary tract, since it

eventually leads to decompensation of the muscular

conduits and reservoirs, back pressure, and atrophy

of the renal parenchyma. It also invites infection

and stone formation, which is cause additional

damage and can ultimately end in complete

unilateral or bilateral destruction of the kidneys.

Complete obstruction leads to rapid

decompensation of the system proximal to the site

of obstruction. Partial obstruction leads to gradual

progressive muscular hypertrophy followed by

dilatation, decompensation, and hydronephrotic

change.

Hydronephrosis is the swelling of a kidney

due to a build-up of urine. It happens when urine

cannot drain out from the kidney to the bladder

from a blockage or obstruction. Hydronephrosis

can occur in one or both kidneys. Hydronephrosis

(kidney swelling) occurs as the result of a disease.

It is not a disease itself. Conditions that are often

associated with unilateral hydronephrosis include:

Nephrolithiasis (kidney stones).

A kidney stone, also known as a renal

calculus, is a solid concretion or crystal

aggregation formed in the kidneys from dietary

minerals in the urine. Urinary stones are typically

classified by their location in the kidney

(nephrolithiasis), ureter (ureterolithiasis), or

bladder (cystolithiasis), or by their chemical

composition (calcium-containing, struvite, uric

acid, or other compounds). About 80% of those

with kidney stones are men.

Kidney stones typically leave the body by

passage in the urine stream, and many stones are

formed and passed without causing symptoms. If

stones grow to sufficient size (usually at least 3

millimeters (0.12 in)) they can cause obstruction of

the ureter. Ureteral obstruction causes postrenal

azotemia and hydronephrosis (distension and

dilation of the renal pelvis and calyces), as well as

spasm of the ureter. This leads to pain, most

commonly felt in the flank (the area between the

ribs and hip), lower abdomen, and groin (a

condition called renal colic). Renal colic can be

associated with nausea, vomiting, fever, blood in

the urine, pus in the urine, and painful urination.

Renal colic typically comes in waves lasting 20 to

60 minutes, beginning in the flank or lower back

and often radiating to the groin or genitals. The

diagnosis of kidney stones is made on the basis of

information obtained from the history, physical

examination, urinalysis, and radiographic studies.

Ultrasound examination and blood tests may also

aid in the diagnosis.

Clinical findings

A male patient 36 years old came to the

surgery polyclinic of Muhammad Hoesin General

Hospital in Palembang after being referred by AK

Gani Hospital with the chief complain sore at the

left waist. Based on auto anamnesis and allo

anamnesis of the present illness, about 1 and half

months ago, the patient complains he had a sore

waist. Before, he also felt the same, but he thought

it was just usual sore waist, but 1 and half month

ago, the pain became more serious, especially after

sat for long time and after lifted something heavy.

Then he went to the internal specialist at Muara

Enim Hospital to consult the pain, he had fever (-),

nausea (-), vomiting (-), loss weight (-), loss

strength (-), pallor (-), urinary dripping (-),

continuous urinary (-), urgency urinary (-), normal

urine color, hematuria (-) but the frequencies and

the quantity were lower than normal, normal stool.

At the specialist doctor, he done the kidney USG

and the result is kidney tone. Then at the other day,

he went to the hospital to do another examination.

At the hospital he had done blood test and BNO

IVP test. The blood test result was normal but the

BNO result saw that he got hydronephrosis grade II

at the left kidney due to obstruction by staghorn

calculi. So the doctor told him to take the surgery.

At the other day he went to the surgery department,

but the doctor said the stone was already big, so the

doctor referred the patient to the hospital at

Palembang.

±17 days before admission to the hospital,

the patient go to Palembang, he go to AK Gani

hospital, but AK Gani hospital does not has a

complete equipment to do the surgery, so the

hospital referred him to Mohammad Hoesin

hospital.

±10 days before admission, he came to

polyclinic Mohammad Hoesin Hospital to consult

pain at the waist area, pain became worsened,

especially after sat for long time and after lifted

something heavy, fever (-), nausea (-), vomiting (-),

loss weight (-), renal colic (+), pain at the rear side

(+), joint pain at legs (-), sore feet (-), numbness at

legs (-), urinary dripping (-), continuous urinary (-),

urgency urinary (-), normal urine color but the

frequencies and the quantity were lower than

normal, normal stool, edema (-), erithema (-).

History of past illness the patient had the

same complain at 2010, he just controlled once and

the doctor said that he had a kidney stone, the

doctor gave some drugs, and he never come back

for control. History of trauma (-), history of stroke

(-), history of use catheterization (-), history of

hypertension (-), history of diabetic (-). There is no

same complaint as the patient in the family.

From physical examinations, general

examination was normal. On local examination,

abdomen was within normal limit, there was

tenderness at CVA region at the left area and

enlarged kidney palpable. External genitalia

examination, from inspection there is no urethra

bloody discharge. On rectal touched examination

TSA good, upper boarder of prostate unpalpable,

rubbery consistency, flat surface, faces (-), blood

(-). Laboratory examination, revealed a increase in

erithrosit (8.14), increase calcium (113), and

creatinine (1.32).

From plain BNO examination of this

patient, the result shows the radio opaque at the

pelvic renalis (staghorn calculi) at the upper left

abdomen and the right abdomen, but the left one is

more bigger than the right one, from IVP test, from

the contrast ultravist there is no allergic reaction,

from the nephrogam the secresion and excresion

from both kidney are normal, pelvicocalics system

(PCS) right is normal and left is extacis grade II,

both left and right ureter are normal, bully-bully

size and shapes are normal, post miksi residu urine

little. Result suspect hydronephrosis grade II at the

left kidney due to staghorn stone obstruction.

(Figure 1 and Figure 2)

The patient is diagnosing as hydronephrosis

sinistra et causa partial staghorn stone obstruction

sinistra. Prognosis for this patient quo ad vitam and

quo ad functionam is bonam.

Figure 1

Figure 2

Figure 3

Discussion

Hydronephrosis is the swelling of a kidney

due to a build-up of urine. It happens when urine

cannot drain out from the kidney to the bladder

from a blockage or obstruction. Hydronephrosis

can occur in one or both kidneys. Hydronephrosis

(kidney swelling) occurs as the result of a disease.

It is not a disease itself. Conditions that are often

associated with unilateral hydronephrosis include:

Nephrolithiasis (kidney stones).

A kidney stone, also known as a renal

calculus, is a solid concretion or crystal

aggregation formed in the kidneys from dietary

minerals in the urine. Urinary stones are typically

classified by their location in the kidney

(nephrolithiasis), ureter (ureterolithiasis), or

bladder (cystolithiasis), or by their chemical

composition (calcium-containing, struvite, uric

acid, or other compounds). About 80% of those

with kidney stones are men.

When a stone causes no symptoms,

watchful waiting is a valid option. For symptomatic

stones, pain control is usually the first measure,

using medications such as nonsteroidal anti-

inflammatory drugs or opioids. More severe cases

may require surgical intervention. For example,

some stones can be shattered into smaller

fragments using extracorporeal shock wave

lithotripsy. Some cases require more invasive

forms of surgery. Examples of these are

cystoscopic procedures such as laser lithotripsy or

percutaneous techniques such as percutaneous

nephrolithotomy. Sometimes, a tube (ureteral stent)

may be placed in the ureter to bypass the

obstruction and alleviate the symptoms, as well as

to prevent ureteral stricture after ureteroscopic

stone removal.

This patient generally present with chief

complaint of sore at the left waist for the past 1 and

half month, especially after sat for long time and

after lifted something heavy, urinary dripping (-),

continuous urinary (-), force urinary (-), trauma (-),

history of operation (-), history of used

catheterization (-), normal urine color but the

frequencies and the quantity were lower than

normal. From all those symptoms indicated

obstruction at the upper urinary tract which is

commonly found in patient with supravesical

obstruction due to uretral stone.

On physical examination, when the upper

urinary tract abnormalities occurs, sometimes

kidney may be palpable and if pyelonephritis

happens it will be accompanied by pain and

percussion pain at the waist area.

In this patient, from the physical

examination on CVA region there was tenderness,

local examination of suprapubic region there was

no tenderness. From external genitalia examination,

from inspection the urine clear, no bloody urine,

and no continuous urinary. On the rectal

examination, no enlargement prostate, smooth

surface, no tenderness, blood (-), feces (-).

Evidence of urinary tract infection,

hematuria, or christalluria may be seen.

Leukocytosis is to be expected in the acute stage of

infection. Little if any elevation of the white blood

count accompanies a chronic stage. In the present

of significant bilateral hydronephrosis, urine flow

through the renal tubules is slowed. Thus, urea is

significantly reabsorbed but creatinine is not. Blood

chemistry therefore reveals a urea-creatinine ratio

well above the normal 10:1. BSS to find possibility

of diabetic that can cause neurological bladder. A

24-hour urine collection for calcium may reveal

hypercalciuria, which occurs with

hyperparathyroidism and idiopathic hypercalciuria.

A qualitative test for urinary cystine should be part

of the routine evaluation. Total renal function will

be impaired if the stones are bilateral and

particularly if chronic infection complicates the

clinical presentation. A pH of 7.6 or higher implies

the presence of urea-splitting organisms. A pH

consistently below 5.5 is compatible with the

formation of uric acid or cystic stone. If pH is fixed

between 6.0 and 7.0, renal tubular acidosis should

be considered as a cause of nephrocalcinosis.

In this patient, the laboratory results found

that increase in erithrosit (8.14), increase calcium

(113), and creatinine (1.32). From this result we

can take conclusion that there is a little bit blood at

the urine, and hypercalciuria.

The plain abdominal (BNO) examination is

used to look for the opaque stone in the urinary

tract, the presence of stone and sometimes may

show a shadow of bladder that filled with urine

which is the sign of a urinary retention. And also to

know the present of bone metastases of prostate

carcinoma. From IVP we can see the place of

obstruction and the obstruction degree. In this

patient, there are opaque stone in the left pelvic

area and there is sign of urinary retention because

there is no urethral catheter fixed in the patient.

After patient has been evaluated, they

should be informed of the various therapeutic

option for upper urinary tract obstruction. Specific

treatment recommendation can be offered for

certain groups of patients. On the other end of the

therapeutic spectrum, absolute surgical indications

include refractory urinary retention, recurrent

urinary tract infection from the job of the patient

and partial staghorn stone obstruction. From the

anamnesis, physical examination, laboratory, BNO

finding this patient has been diagnosed of

hydronephrosis sinistra e.c partial staghorn stone

obstruction sinistra. The most suitable treatment for

this patient is ureterorenoscopy URS sinistra and

pyeloletotomy sinistra. Beside medication and

surgery patient should also be given proper

education before surgery. Patient should be

educated about to change of lifestyle could

improving the quality of living. Firstly reeducation

of fluid intake at specific times, recommended total

daily fluid intake is 2L per day. Secondly, take

some exercise so that every part of the body can

work properly. Third, control to the doctor as the

scheduled.

Conclusion

This case report we found that the patient chief

complain was pain at the hip. From the anamnesis

we can conclude that he feel pain when he lifted a

heavy thing, after take a long sit, pain at the rear

side, pain radiate to the lower spine, done less

activity, less drink water, but there is no pain when

urination, no bleeding, no continuous urine. From

the physical examination i found that CVA region

there was tenderness, palpable enlargement of

kidney, but from the external genitalia theres no

abnormality. From the lab test there was slightly

increase at the erithrosit, calcium, and creatinine.

From the BNO we can see the opaque stone at the

left pelvic area. From the information it has

presented upper tract symptom along with physical

rectal examination and BNO which point to see the

obstruction that cause by staghorn stone at the renal

pelvic. Further investigation of pathology and

anatomy using BNO to confirm the diagnosis of the

hydronephrosis. Later to that, this patient had to

undergo nefrolitotomy. Following surgical

treatment, patients may be seen within 2 weeks to

discuss the histological findings and to identify

early post – operative morbidity. Long term follow

up should be scheduled at 3 months to determine

final outcome.

Reference

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