外科学教学课件：泌尿系结石（全英文）

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1、Urolithiasis Urolithiosis is a common disease in urology.Which have afflicted humankind since antiquity.Section I Overview The prevalence of urinary tract stone disease is estimated to be 1%to 15%.Section II Epidemiologic Aspects Upper urinary tract calculi,95%Lower urinary tract calculi,5%They cont

2、ain crystal(97%)and matrix(3%)Intrinsic Factors Metabolic abnormalities:Hypercalcemic NephrolithiasisLocal factors(secondary stone forming factors):Urinary tract infections Genetics Age and Sex Etiology Section IIICauses of urinary stone formation Extrinsic Factors Climates Diet Drugs Melamine（三聚氰胺）

3、三聚氰胺）Prevention principles防治总则防治总则 There are two main purpose：1.Remove the causes，2.Stones clearance,kidney function protection.Section IV Prevention principals 1.Drug therapy Dissolve stonesPrevention of stonesMET(medicine expulsion of stones):The diameter4mm,the rate of spontaneous expulsion is ab

4、out 80%.4mm:50%;6mm:20%；Diameter greater than 10mm,rarely dischargedSection IV Prevention principals 2.Surgical therapy 2.1 indications for intervention Stone diameter is less than 4mm,the spontaneous stone passage(SSP)自行排石自行排石 rate is likely to 80%,5mm 50%,6mm 20%，10mm rarely.Ureteral stones SSP ra

5、te:upper 25%,middle 45%,distal 70%.2.2 Treatment principles and order of bilateral renal stones Upper urinary tract calculi accounted for 5%-10%,the principles are protecting renal function.The operative principle of bilateral upper tract calculus a.unilateral ureteral stones and contralateral renal

6、 stones:urteral stones first prior to contralateral renal stone.b.bilateral ureteral stones:severe obstructive side first.Or easy to handle side first.c.bilateral ureteral stones:if renal function normal,decreased function side first;If poor renal function or general condition,better renal function

7、side first;contralateral kidney nephrostomy,waiting for the better condition.bilateral upper urinary tract stone or separated kidneys upper tract stone causes acute complete obstruction:general condition permitted,operate immediately.If the general condition is too bad to perform operation,wed bette

8、r do nephrostomy.Water intakeUrine volumes2000ml/24hDietary intake:high meat intake increase the urinary restriction of calcium,oxalate,low oxalate content dietary.3.Diet therapySection V Renal calculi 1.Pain and hematuria The major symptom is hematuria and pain.Almost all hematuria is microscopic h

9、ematuria.The degree of hematuria and pain is related with location,size active and complication.Clinical Presentation the small the stone is,the more prominent symptoms are.The stone locates neck of calyx,producing obstruction or in pelvis and moves inactively,symptoms show dull pain in upper abdome

10、n.Renal colic.Renal or ureteric colic is a symptom complex that is characteristic for the presence of obstructing urinary tract calculi.Stone locates ureter pelvic link,or upper ureter,pain is renal colic in upper abdomen or low.Complicating nausea,vomiting.The pain radiates to same side testis or a

11、nd medial thigh.A urinary calculus usually presents with an acute episode of renal or ureteral colic as the result of a stone obstructing the urinary tract.There are five locations where stones can be impacted in the urinary tract:calyx of the upper urinary tract,ureteropelvic junction,the ureter be

12、gins to arch over the iliac vessels,the posterior pelvis,the ureterovesical junction,which is the most common site of impaction.Bilateral upper tract stone or of separated kidney producing complete obstruction results in active renal failure,no urine.2.Spontaneous stones passage 3.InfectionA.history

13、:hematuria and pain relating with 1.laboratory examination:(1)Urine routine:microscopic hematuria,pyuria.(2)Blood test:White blood cell(WBC)13109/L,indicating UTI.Hyperparathyroidism,Bacterial culture of urine.(3)Stone analysis:stone specimens come from surgery,lithotripsy,spontaneously stone passag

14、e.(4)24 hour urine quantitative analysis:calcium,phosphorus,inosine,alkaline phosphatase,uric acid,protein in blood and uric calcium,uric and insoine oxalic acid in 24 hour urine.(5)Measuring renal function.Diagnosis Location:When stone locates middle ureter,renal colic radiates middle and lower abd

15、omen.Stone locates ureterovesical wall ureter oriface,irritative voiding symptoms and radiative pains of penis head and urethra.Stone complicates infection,infective symptoms of urinary system may be present.DiagnosisDiagnosis2.Diagnosis of image(1)B-ultrasound(2)KUB film:90%kidney stones are positi

16、ve with plain abdominal film.(3)intravenous urogram(IVU):uric acid stone(negative)show filling defect.(4)CT:With high diagnosis accuracy,however,due to large amount of radiation,expensive,not being the first choosing method.Staghorn calculiKUBIVUCholecytitis胆囊炎胆囊炎,choletithiasis胆结石胆结石,acute appendic

17、itis阑尾炎阑尾炎,torsion of ovarian cyst卵巢卵巢扭转扭转.The similarity of these symptoms to those arising from the gastrointestinal tract causes renal colic to be confused with a number of abdominal diseases,including gastroenteritis,acute appendicitis,colitis,and salpingitis输卵管输卵管炎炎.Differential Diagnosis Conse

18、rvative treatment indication:stone diameter is less than 0.6 cm,and smooth,there are no obstruction and infection.Uric acid or cystine stone.Treatmentu observe urination every timeu intake a great quantity of wateru regulating foodu controlling infectionu regulating urinary PH:alkalization or acidiz

19、ation of according to the stone analysis.u Cystine stone:alkalizationu Infective stone:acidizationTreatmentu Renal colic treatment:dolantin杜冷丁杜冷丁(镇痛剂镇痛剂)100mg im.uChinese western medicineTreatmentuUric acid(尿酸尿酸)stone treatment:alkalization of urineuInfective stone treatment:control infection and ac

20、idization of urine.uCystine stone treatment:alkalization of urine,Thiola(巯醇巯醇).Treatment1.Extracorporeal shock-wave lithotripsy(ESWL)or SWL(体外体外)冲击波碎石术冲击波碎石术 Shock waves by source released spread in vivo from in vitro.Which is a less invasive procedure than percutaneous nephrolithotomy(PCNL)经皮肾镜取石术经

21、皮肾镜取石术.Indication and contraindications for ESWL Indication适应症：适应症：ESWL becoming the preferred treatment method for renal stones less than 2cm in large diameter.(2cm结石的结石的首选治疗方法首选治疗方法)Absolute contraindication绝对禁忌症绝对禁忌症:pregnant women妊娠妇女妊娠妇女.Relative contraindication:distal urineral tract stenosis,

22、coagulopathy,oliguric renal failure少尿少尿性肾衰性肾衰,acute urineral tract infeciton(UTI)急性急性尿路感染尿路感染,severe arrythmia严重心律失严重心律失常常,diameter in excess of 2cm.2.Percutaneous nephrolithotomy，PCNL 经皮肾镜碎石术经皮肾镜碎石术 Indication:diameter in excess 2cm.3.Opened operation Operative treatment:Before operation,bilateral

23、renal function should be known to see whether infected.uureterolithectomy 输尿管切开取石术输尿管切开取石术upyelolithectomy 肾盂切开取石术肾盂切开取石术TreatmentTreatmenturenal sinus-pyelolithectomy 肾窦肾盂切肾窦肾盂切开取石术开取石术urenal-parenchymalithectomy 肾实质切肾实质切开取石术开取石术unon-atrophy nephrolithectomy 无萎缩无萎缩性肾切开取石性肾切开取石upartial nephrectomy部分

24、肾切除术部分肾切除术uclotting pyelolithectomy 凝固法结石去凝固法结石去除除uNephrectomy肾切除术肾切除术 Ureteral calculi account for 65%of upper urinary tract.The ureter is divided into three sections:upper(proximal),middle and lower(distal).Section VIUreteral calculiKUBIVPuppermiddlelower Ureteric colic Microscopic or gross hematu

25、ria.Spontaneous stone passage SSP排石排石(结石自行结石自行排出排出)Pyuria 脓尿脓尿Section VIUreteral calculiClinical Presentation Ultrasound(Doppler ultrasound examination)is a noninvasive method of demonstrating both the urinary stone and the consequent hydronephrosis.In several institutions,it has supplanted IVU as t

26、he diagnostic test.Plain kidney-ureter-bladder,(KUB)Radiographs intravenous injection urographic films(IVU)Retrograde Pyelography(RP)逆行肾盂造影逆行肾盂造影 Spiral Computed Tomography螺旋螺旋CTDiagnosis Ultrasound is a noninvasive method of demonstrating both the urinary stone and the consequent hydronephrosis.Ret

27、rograde pyelography is necessary only the stones are difficult to locate by other techniques.CT scanning has been used clinically with increasing frequency.Diagnosis1.Shock-wave lithotripsy(SWL)was a treatment for ureteral stones in the early 1980s.Today,SWL remains the primary treatment for most un

28、complicated upper urinary tract calculi.Treatment2.Ureteroscopy has traditionally constituted the favored approach for the surgical treatment of mid and distal ureteral stones while SWL has been preferred for the less accessible proximal ureteral stones.Treatment3.Percutaneous antegrade removal of u

29、reteral stones is a consideration in selected cases,for the treatment of very large(15 mm diameter)impacted stones in the proximal ureter between the ureteropelvic junction and the lower border of the fourth lumbar vertebra.Treatment4.Laparoscopic ureterolithotomy is a better alternative than open s

30、urgery if expertise in laparoscopic techniques is available.Bladder calculi account for 5%of urinary calculi and usually occur because of bladder outlet obstruction(BOO),neuro-genic bladder,infection,and foreign bodies.5There is no agreement about the preferred method of treating bladder calculi in

31、patients with associated BOO caused by BPH.Section VIIVesical calculi In contrast to renal stones,bladder stones are usually composed of uric acid(in noninfected urine)or struvite(in infected urine).Typical symptoms of vesical stone膀胱结石膀胱结石 are intermittent,painful voiding and terminal hematuria.Cli

32、nical Presentation Discomfort may be dull钝痛钝痛,aching,or sharp suprapubic pain,which is aggravated by exercise and sudden movement.Severe pain usually occurs near the end of micturition排尿排尿,as the stone becomes impacted at the bladder neck.Relief may be afforded by assuming a recumbent position.The p

33、ain may be referred to the tip of the penis,the scrotum,or the perineum and on occasion to the back,the hip,or even the heel or sole of the foot.Besides pain,there may be an interruption of the urinary stream from impaction of the stone at the bladder neck or urethra.Priapism异常勃起异常勃起 and nocturnal e

34、nuresis遗尿遗尿 may occur in children.Evidence of vesical calculi is not seen in plain films because of the presence of uric acid in many of the calculi and because of overlying prostatic tissue.Such stones form negative shadows in the Cystogram phase of IVU.Ultrasonography is useful for detecting radio

35、lucent calculi.Cystoscopic Examination is the surest method for detecting vesical calculi.DiagnosisVescical caculi Transurethral approach is the preferred modality to remove small stones.Holmium laser is very versatile to take care of any bladder stones.If laser is not available,one may pass Nephros

36、cope per urethrally and use pneumatic lithotripter for stone fragmentation.Treatment For larger stones one may have access bladder through percutaneous suprapubic route and use Nephroscope and neumatic lithotripter for stone fragmentation.A very large stone 4cm in diameter in a neurogenic bladder on

37、e may remove with a small suprapubic incision in a short time with minimal morbidity.Treatment Commonly accepted modalities include transurethral or percutaneous cystolithotomy,open cystolithotomy,and extracorporeal shock wave lithotripsy(SWL).Treatment Most urethral calculi in men consist of stones

38、 expelled from the bladder into the urethra.Section VIIIUrethral Calculi A stone in the anterior urethra may be grasped and removed with forceps.Lithotripsy and removal of a stone via the urethroscope may be advisable.TreatmentESWL体外冲击波碎石PCNL经皮肾镜Ureteroscopy输尿管镜Minimally invisive management options for urolithiasis泌尿系结石微创治疗方法泌尿系结石微创治疗方法