外科学课件：泌尿系结石（英文版）

Urolithiasis

Overview

Urolithiosisisacommondiseaseinurology.whichhaveafflictedhumankindsinceantiquity.SectionI

Theprevalenceofurinarytractstonediseaseisestimatedtobe1%to15%.SectionIIEpidemiologicAspects

Upperurinarytractcalculi,95%Lowerurinarytractcalculi,5%Theycontaincrystal(97%)andmatrix(3%)CausesofurinarystoneformationIntrinsicFactorsMetabolicabnormalities:HypercalcemicNephrolithiasisLocalfactors(secondarystoneformingfactors):Urinarytractinfections

GeneticsAgeandSexEtiology

SectionIII

ExtrinsicFactorsClimatesDietDrugsMelamine（三聚氰胺）Preventionprinciples

SectionIV

Therearetwomainpurpose：1.Removethecauses，2.Stonesclearance,kidneyfunctionprotection.1.Drugtherapy

DissolvestonesPreventionofstonesMET(medicineexpulsionofstones):Thediameter≤4mm,therateofspontaneousexpulsionisabout80%.4mm:50%;≥6mm:20%；Diametergreaterthan10mm,rarelydischargedSection

IV

2.Surgicaltherapy

a.bilateralureterolith:severeobstructivesideb.

unilateralureterolithandcontralateralrenalstone:urterolithfirstbilateralrenalstone.Theoperative

principleofbilateraluppertractcalculus

Bilateralrenalstone

Principle:a.

protectingkidneyb.

easyandsafesidefirstc.

ifrenalfunctiondecreases,severeobstructionorgeneralconditionispoor,nephrostomyfirst,waitingforthebetterconditionbilateralupperurinarytractstoneorseparatedkidney’suppertractstonecausesacutecompleteobstruction:generalconditionpermitted,operateimmediately.Ifthegeneralconditionistoobadtoperformoperation,we’dbetterdonephrostomy.

Waterintake

Urinevolumes＞2000ml/24hDietaryintake:useoflargeamountsofWorcestershiresaucewithitshighoxalatecontent3.DietherapySectionV:

Renalcalculi

Themajorsymptomishematuriaandpain.Almostallhematuriaismicroscopichematuria..Thedegreeofhematuriaandpainisrelatedwithlocation,sizeactiveandcomplication

.ClinicalPresentationthesmallthestoneis,themoreprominentsymptomsare.Thestonelocatesneckofcalyx,producingobstructionorinpelvisandmovesinactively,symptomsshowdullpaininupperabdomen.3)

Renalcolic.

Renaloruretericcolicisasymptomcomplexthatischaracteristicforthepresenceofobstructingurinarytractcalculi.Stonelocatesureterpelviclink,orupperureter,painisrenalcolicinupperabdomenorlow.Complicatingnausea,vomiting.Thepainradiatestosamesidetestisorandmedialthin.Aurinarycalculususuallypresentswithanacuteepisodeofrenalorureteralcolicastheresultofastoneobstructingtheurinarytract.Therearefivelocationswherestonescanbeimpactedintheurinarytract:①calyxoftheupperurinarytract,②ureteropelvicjunction,③theureterbeginstoarchovertheiliacvessels,④theposteriorpelvis,⑤theureterovesicaljunction,whichisthemostcommonsiteofimpaction.Therearefivelocationswherestonescanbeimpactedintheurinarytract:①calyxoftheupperurinarytract,②ureteropelvicjunction,③theureterbeginstoarchovertheiliacvessels,④theposteriorpelvis,⑤theureterovesicaljunction,whichisthemostcommonsiteofimpaction.7)

Bilateraluppertractstoneorofseparatedkidneyproducingcompleteobstructionresultsinactiverenalfailure,nourine.A.history:hematuriaandpainrelatingwithactionLaboratoryexamination:1)

Urineroutine:microscopichematuria,pyuria.2)

Bacterialcultureofurine3)

Measuring:calcium,phosphorus,inosine,alkalinephosphatase,uricacid,proteininbloodanduriccalcium,uricandinsoineoxalicacidin24hoururine.4)

Measuringrenalfunction.DiagnosisWhenstonelocatesmiddleureter,renalcolicradiatesmiddleandlowerabdomen.5)

Stonelocatesureterovesicalwallureteroriface,irritativevoidingsymptomsandradiativepainsofpenisheadandurethra.6)

Stonecomplicatesinfection,infectivesymptomsofurinarysystemmaybepresent.DiagnosisDiagnosisC.Diagnosisofimage1)

KUBfilm:>95%stonecanbefoundinKUB.2)

IVP:uricacidstone(negative)showfillingdefect.3)

B-ultrasound4)

Hyperparathyroidism:shoulddohand,rib,vertebralcolumn,pelvisandfemoralhand.StaghorncalculiKUBIVPCTscanning(2)

ureteropelvicscopeDiagnosischolecytitis,choletithiasis,acuteappendicitis,torsionofovariancyst.Thesimilarityofthesesymptomstothosearisingfromthegastrointestinaltractcausesrenalcolictobeconfusedwithanumberofabdominaldiseases,includinggastroenteritis,acuteappendicitis,colitis,andsalpingitis.DifferentialDiagnosis

1)

Conservativetreatmentindication:stonediameterislessthan0.6cm,andsmooth,therearenoobstructionandinfection.Uricacidorcystinestone.Treatment

1）observeurinationeverytime2)

intakeagreatquantityofwater3)

regulatingfood4)

controllinginfection5)

regulatingurinaryPH:alkalizationoracidizationofaccordingtothestoneanalysis.Cystinestone:alkalizationInfectivestone:acidizationTreatment

6)

renalcolictreatment:dolantin100mgim.7)

ChinesewesternmedicineTreatment8)

Uricacid(尿酸)stonetreatment:alkalizationofurine9)

Infectivestonetreatment:controlinfectionandacidizationofurine.Cystinestonetreatment:alkalizationofurine,Thiola(巯醇).ESWL(Extracorporsalshockwavelithotripsy体外冲击波碎石).TreatmentExtracorporealshock-wavelithotripsy(ESWL)isalessinvasiveprocedurethanpercutaneous

nephrolithotomy.Operation(1)

Operativetreatment:Beforeoperation,bilateralrenalfunctionshouldbeknowntoseewhetherinfected.1)

unopenedoperation2)

openedoperationa.

ureterolithectomy输尿管切开取石术b.

pyelolithectomy肾盂切开取石术TreatmentTreatmentc.

renalsinus-pyelolithectomy肾窦肾盂切开取石术d.

renal-parenchymalithectomy肾实质切开取石术e.

non-atrophynephrolithectomy无萎缩性肾切开取石f.

partialnephrectomyg.

clottingpyelolithectomy凝固法h.

nephrectomyUretericcolicMicroscopicorgrosshematuria.Stonedischarge排石Pyuria脓尿SectionVI:

UreteralcalculiClinicalPresentationUltrasound(Dopplerultrasoundexamination)isanoninvasivemethodofdemonstratingboththeurinarystoneandtheconsequenthydronephrosis.Inseveralinstitutions,ithassupplantedIVUasthediagnostictest.

Plainkidney-ureter-bladder,(KUB)Radiographsintravenousinjection

urographic

films(IVU)RetrogradePyelography

ComputedtomographyDiagnosisUltrasoundisanoninvasivemethodofdemonstratingboththeurinarystoneandtheconsequenthydronephrosis.Retrogradepyelographyisnecessaryonlythestonesaredifficulttolocatebyothertechniques.

CTscanninghasbeenusedclinicallywithincreasingfrequency.DiagnosisShock-wavelithotripsyasatreatmentforureteralstonesintheearly1980s.Today,SWLremainstheprimarytreatmentformostuncomplicatedupperurinarytractcalculi.TreatmentUreteroscopyhastraditionallyconstitutedthefavoredapproachforthesurgicaltreatmentofmidanddistalureteralstoneswhileSWLhasbeenpreferredforthelessaccessibleproximalureteralstones.TreatmentPercutaneousantegraderemovalofureteralstonesisaconsiderationinselectedcases,forthetreatmentofverylarge(＞15mmdiameter)impactedstonesintheproximalureterbetweentheureteropelvicjunctionandthelowerborderofthefourthlumbarvertebra.Treatmentlaparoscopicureterolithotomyisabetteralternativethanopensurgeryifexpertiseinlaparoscopictechniquesisavailable.Bladdercalculiaccountfor5%ofurinarycalculiandusuallyoccurbecauseofbladderoutletobstruction(BOO),neuro-genicbladder,infection,andforeignbodies.5ThereisnoagreementaboutthepreferredmethodoftreatingbladdercalculiinpatientswithassociatedBOOcausedbyBPH.SectionVII:

VesicalcalculiIncontrasttorenalstones,bladderstonesareusuallycomposedofuricacid(innoninfectedurine)orstruvite(ininfectedurine).Typicalsymptomsofvesicalstoneareintermittent,painfulvoidingandterminalhematuria.ClinicalPresentation

Discomfortmaybedull,aching,orsharpsuprapubicpain,whichisaggravatedbyexerciseandsuddenmovement.Severepainusuallyoccursneartheendofmicturition,asthestonebecomesimpactedatthebladderneck.Reliefmaybeaffordedbyassumingarecumbentposition.Thepainmaybereferredtothetipofthepenis,thescrotum,ortheperineumandonoccasiontotheback,thehip,oreventheheelorsoleofthefoot.Besidespain,theremaybeannterruptionoftheurinarystreamfromimpactionofthestoneatthebladderneckorurethra.Priapismandnocturnalenuresismayoccurinchildren.Evidenceofvesicalcalculiisnotseeninplainfilmsbecauseofthepresenceofuricacidinmanyofthecalculiandbecauseofoverlyingprostatictissue.SuchstonesformnegativeshadowsinthecystogramphaseofIVU.Ultrasonographyisusefulfordetectingradiolucentcalculi.Cystoscopicexaminationisthesurestmethodfordetectingvesicalcalculi.DiagnosisVescicalcaculiTrans