المرحلة الرابعة
د. محمد فوزيجراحة بولية
المرحلة الرابعة
د. محمد فوزي
جراحة بولية
URINARY STONES
التسلسل: 7
التاريخ: 12/11/2018
العدد: 4
التسلسل: 7
التاريخ: 12/11/2018
العدد: 4
CALCULAR DISEASE
Incidence:
Common, affecting 10-20% of population.
Males affected more than females.
Occurs mainly in middle age, but no age immune.
2/3 patients have recurrence within 8 years.
Aetiology:
1-Geography: tropical area, mountainous and Mediterranean countries.
2-Climate: direct relationship between temp and stone incidence.
3-low Water intake:
4-Diet:
5-Socio-economic status:
6-Metabolic & endocrinal factors:
I- Ca++ oxalate & Ca++ phosphate calculi:
Hypercalcemia (hyperparathyroidism)
Hypercalciuria.
Hyperoxaluria: primary (congenital), secondary (enteric disease) or idiopathic (dietary).
Hypocitraturia: .
Hyperuricosuria:
Renal tubulal acidosis:
associated with hypercalciuria & hypocitraturia.
II- Uric acid calculi:
Hyperuricemia and hyperuricosuria.
III-Cystine calculi: hereditary cystinuria.
IV-Xanthine calculi:hereditary xanthinuria
7-Infection: UTI due to urea splitting MO (urease producing MO) causes urine alkalinazation hence phosphate precipitation. (triple phosphate stones).
8-Congenital anomalies.
Types of renal calculi
I-Calcium stones: 70%, radio-opaque.a-Calcium Oxalate
Calcium oxalate monohydrate
Calcium oxalate dihydrate
b- Calcium phosphate calculi:
II- Triple phosphate calculi (Struvite):
Grows very rapidly in alkaline urine, radio-opaque
III- Uric acid calculi: hard, smooth and golden yellow.
Pure uric acid stones are radiolucent.
presentations:
1-Asymptomatic.2-Loin pain.
3-uretric colic.
4-Hematuria.
5-Infection or pyuria.
6-Renal failure.
Investigations
1- GUE: microscopic hematuria 90%, sterile pyuria and crystalluria.
2- U/S : stone shadow, hydronephrosis and hydroureter. (The whole ureter cannot be visualized).
3- KUB: 90% radio-opaque & soft tissue shadow of hydronephrotic kidney.
Differential diagnosis of radio opaque shadow in KUB
Gall stone, calcific LN, FB, phlebolith, fecolith, calcified TB lesion, chip # oftransverse process, calcified rib tip, calcified fibroid and ovarian dermoid cyst.
4- IVU:
Hydronephrosis, renal function, site of obstruction and filling defects in radiolucent stones.
5- CT scan & MRI (BEST INVESTIGATION)
6-urethroscope, cystoscope, ureteroscope and nephroscope
7- Endoscopic:
Management of urinary stones
Aims:Relief pain
Treat the infection .
Stone removal.
Prevention of recurrence.
Renal colic: strong analgesia, NSAID (Diclfenac 75 mg im) or narcotics (Pethidin 50-100 mg im).
Hydration in dehydration.
Antibiotics in renal infection.
Hospitalization may be needed.
Interventional treatment:
Repeated attacks of pain &the stone is not progressing.Stone is enlarging with time.
Complete obstruction of the kidney.
Symptoms & signs of infection.
Stone is too large to pass.
Stone is obstructing solitary kidney or there is bilateral obstruction.
Impaired renal function( elevated urea & creatinine).
Methods of renal stone treatment
ConservativeExtracorporeal shock wave lithotripsy (ESWL).
Ureteronephroscopy with laser (RIRS)
Percutaneous nephrolithotomy (PCNL).
Combination.like ESWL AND PCNL
Open surgery
Chemolysis
Conservative treatment
Stones less than 5mm have 50% chance of spontaneous passage.
High fluid intake,offer pain relief ,treating infection ,incourage mobility and follow up.
ESWL
Indications: all stones less than 2 cm in the kidney and less than one cm in ureter.
Contraindications: bleeding tendency, , ureteric obstruction, pregnancy, skeletal anomaly and overweight.
Complications of ESWL:
Failure of stone fragmentation.Hematuria.
Ureteric colic.
Ureteric obstruction (stone street)
Infection.
Rapid recurrence due to residual fragments.
PCNL:
Using lithotripsy(stone fragmentation) through percutaneous nephroscope to retrieve the renal stonesIndications of PCNL
*ESWL Failure or contrindicatedones >*sone more than 2 cm
*staghorn stone
*Lower pole stone.
In Combination with ESWL in large stone (sandwich methode)
Advantages
*Small endoscopic wound
*Mild post operative pain.
*Short hospital stay.
Complications of PCNL
Nearby organ injury eg colon, duodenum, spleen and pleura.Bleeding.
Failure to get the stone.
Residual stones.
Open surgery
Indications:If ESWL or PCNL are contraindicated or failed
Pyelolithotomy.
Nephrolithtomy.
Pyelonephrolithotomy.
Partial nephrectomy.
Nephrectomy
Dissolution agents chemolysis
oral alkalinizing agents for uric acid & cystine stonesAcidification in struvite tone
Methods of ureteric stones treatment
Conservative(stone less than 5-6 mm)
ESWL
Ureteroscopic lithotripsy
surgery (Ureterolithotomy.)
open
laparoscopic
conservative
is appropriate for small stones.
Spontaneous passage depends on stone size, shape, locationUreteral calculi 4-5 mm in size have a 40-50% chance of spontaneous passage. In contrast, calculi > 6 mm have a less than 5% chance of spontaneous passage
High fluid intake,offer pain relief ,treating infection ,incourage mobility in addition to that we add an alpha blocker drug like tamsulusin to facilitate stone expulsion ( medical expulsive therapy MET ) and follow up
Sites of stone impaction
1-Pelviureteric junction.2-Pelvic brim.
3-Ureterovesical junction.
Indications for intervention
Repeated attacks of pain &the stone is not progressing.Stone is enlarging with time.
Complete obstruction of the kidney.
Symptoms & signs of infection.
Stone is obstructing solitary kidney or there is bilateral obstruction.
Impaired renal function( elevated urea & creatinine).
Ureteroscopic Stone Removal
Small stones removed as one piece using forceps or dormia under direct vision.
Large stones are fragmented using pneumatic, electrohydraulic , or Laser Lithotripter then removed in pieces.
Flexible ureteroscope with dormia basket
Ureterolithotomy
Open UreterolithotomyLaparoscopic Ureterolithotomy
Prevention of recurrence
High fluid intake specially in hot weather.Treatment of infection.
Correction of obstruction or anomalies.
Urine acidification or alkalinazation.
Treatment of associated disorders.
Prevention of certain diets.
Certain drugs (penicillamine, allopurinol).
Urinary bladder stone: (vesical)
Etiology:
Children: dehydration, low protein diet & UTI
Adult:
1- Urinary obstruction: BPH & stricture.
2- UTI.
3- Neurogenic bladder dysfunction.
4- Foreign body.
Clinical pictures
1-Pain: suprapubic pain, penile pain especially at the tip of the penis or labia majora at the end of micturition.2-Frequency of urination.
3-Difficulty in micturition or retention of urine.
4-Hematuria.
Diagnosis of vesical stone
ULTRASOUNDKUB
CT
cystoscopy
Treatment of Vesical Stone
Treat the underlying cause.
Cystolitholapaxy (Endoscopic) :Its minimally invasive technique allowing most stones to be broken and subsequently removed through a cystoscope...stone crushing by electrohydraulic, ultrasonic, laser, and pneumatic lithotrites . Mechanical lithotrites (stone punch) & Elik evacuator.
Suprapubic cystolithotomy
ESWL
Urethral stones
Origin:Most often migrated from the ureter and arrested in the prostatic or bulbous urethra
Less commonly originated in the urethral diverticulum (Ca++ phosphate)
Clinical pictures
*Severe urethral pain during urination.
*Interruption of urine stream.
*Retention of urine.
*Urethral ex.:induration of the stone.
*Click felt by metal bougie.
Treatment of urethral stone
Treat the underlying cause.Small stones may be grasped successfully and removed intact by urethroscopy
pushed back to the bladder,and treated as vesical stone.
Long-standing, large impacted stones are best removed through a urethrotomy.