1尿路結(jié)石2Urolithiasis/calculi/stone結(jié)石(jie

shi)3Urolithiasis

Chapter1

IntroductionUrolithiasisfoundinMummyStonediseasedescribedinChineseancientmedicinedocument4Urolithiasisisoneofthemostcommondiseaseinurology.ItistheNO1diseaseintermofthenumberofpatientsforhospitaladmissioninurologyunit.InChina,IncidentofUrolithiasistendstobeincreasing.Chinaisamongthedistrictsofhighincidenceof

Urolithiasis

intheworld(Include:TheUnitedKingdom、Holland、India、Thailand,etc).

Epidemiologyofstonedisease5

1.Districtdistribution

（high-incidenceintropicalorsubtropicalarea）

2.Genderdistribution

（Man:Woman≈3:1）

3.Agedistribution

（casepredilectionattheageof20～50yearsold)Urolithiasis

Chapter1

IntroductionCharacteristics61.Metabolism-relatedstone

——

Calciumoxalate（67.2％）

Calciumphosphate（22.4％）

Uricacid（6.9％）

Cystine（1.1％）2.Infection-relatedstone——

Magnesiumammoniumphosphate（1.7％）

CategoryofstoneUrolithiasis

Chapter1

Introduction7

Calciumoxalate(CaOx)isthemostcommontypeofhumankidneystone.Introduction8Uricacidcalculi9Magnesiumammoniumphosphate10Urolithiasis

CompositionandpropertiesofdifferentcalculuscompositionproportioncoloursurfaceX-rayU-PH

calciumoxalate

80%

sepia

rough

radiopaquefaintlyacid

grayishyellow

granular

faintlyalkaline

phosphate

10~15%

off-white

brittle

radiopaque

acidic

stratifiedstructureUricacid

5~10%

yolkyellow

smooth,hard

radiolucent

alkaline11Mechanismofstone

formationAsawhole,thecausesforstoneformationremainunclear.Itisacceptedthatmultiplefactorswereinvolvedintheprocessofstoneformation.

Factorsinclude:Metabolicabnormal,Urinarytractlocalfactors,climate,diet,drug,etc.Urolithiasis

12HypothesisofstoneformationRandall’plaquetheoryColloidaltheoryTheoryofmatrixinitiation

TheoryofsupersaturationandnucleationTheoryofsupersaturation-inhibitedimbalance13UrinaryCrystal

Crystal-inhibitedsubstance↓

Supersaturationor

decreaseofsolubilityoftheurinaryCrystal

↓

Crystalformation--→Crystalgrowingup↓

Crystalaggregation

Matrixbinding

--→↓

Crystalretentioninthecollectingduck

--→StoneformationUrolithiasis

Chapter1:Processofthestoneformation14Processofthestoneformation15CausesforStoneformationTheindividualfactorsTheenvironmentalfactors

Metabolicabnormal

Urinarytractlocalfactorsclimate

dietmedicineUrolithiasis

Chapter1

Introduction161.Theindividualfactors:Metabolicabnormal（Differenttypesofstoneshowdifferentmetabolicabnormal）☆Calciumphosphatecalculi：

Renaltubularacidosis（Autosomaldominantinheritance）

Medullaryspongekidney☆Uricacidcalculi：AbnormalofPurinemetabolism☆Cystinecalculi：Cystinuriadisease（Autosomalrecessivehereditarydisease）

CausesforStoneformation17CausesforStoneformation☆Calciumoxalatecalculi(CaOx)

(1)Hypercalciuria

(highlevelofurinarycalcium)（1）Suchashyperparathyroidism,VitD

intoxication,bone

demineralization,etc.

（2）Absorptivehypercalciuria:theincreasedcalciumcontentinthediet，orincreasedintakeofcalciumingutcausedbycertaintypesofintestinaldiseases

（3）Renalhypercalciuria:suchasimpairedcalciumreabsorptioncausedbyrenaltubularacidosis(RTA)，whichincreasetheurinarycalciumlevel.(2)Hyperoxaluria(highlevelofurinaryoxalate)Theincreasedintakeofoxalateintheintestinaltract

①Secondarytoenteritisorextensiveintestinalresection;

②Idiopathy(causedbyeuchromosomerecessiveheredityoroverproductionofoxalateinliver.)(3)Hyperuricosuria(highlevelofurinaryuricacid)

Disorderofthepurinemetabolism→serumuricacidincreased→urinaryexcretionofuricacidincreased→uricacidcalculi→calciumoxalatecalculi(4)Hypocitraturia(Lowlevelofurinarycitrate)18

1.

Theindividualfactors:

Localfactorsofurinarytract

(1)

Urinarytractinfection：

①Thecoreofthecalculuscouldbeformedbybacterialcolony,necrotictissue,etc.

②Certainbacteria,suchasproteus,canresolveureaintoammoniainurine,whichmaketheurinealkaline(堿性),andpromotethephosphateprecipitationinrenalcalyx.CausesforStoneformation19CausesforStoneformation（2）Urinarytractobstruction:①Thesubstancesthatfacilitatelithogenesis(stoneformation)areabsorbedintheurinewhichleadtosupersaturation.②Turbulencescontributedtotheprecipitationoflithogenesis-substancesinurinetract.③Microcalculiisnoteasytobedischarged.20（3）foreignmatterinurinarytract

★Catheterorstent(formedicalpurpose)

★Sutures(absorbableornot)

★Theother

foreignmatter(suchas:metallicring,hairpin----Mentalillness)CausesforStoneformation21CausesforStoneformationDouble-Jstent22CausesforStoneformationHairpininurinarytract232.Environmentalfactors:（1）Dietary

Insufficientintakeofwater

Highproteindiet

Excessive/insufficient

intakeofcalcium

Excessive

intakeofsodium

Insufficient

intakeofmagnesium

Insufficient

intakeofVitA/VitB6

Thereiscloserelationshipbetweenbladdercalculiofpediatricpatientsandmalnutrition.CausesforStoneformation242.Environmentalfactors:(2)ClimateDesudationcausedbyhotclimate----urineconcentration----supersaturationofcrystallinesubstanceinurine.Longtimeexposuretosunshineresultinincreasementof1,25-dihydroxy

vitaminD3，whichinturncontributetotheincreasingofcalcium-absorbingintheintestinaltract.CausesforStoneformation252.Environmentalfactors:(3)Medicine

Glucocorticoid

VitamineC/DSulfonamide（SM）Tripolycyanamide

Ceftriaxoneetc….CausesforStoneformation26Urolithiasis

Pathologyand

Pathophysiology(1)Directdamage

：Itcausemucosalhyperemia,mucosal

edema,mucosalanabrosisorecclasis,proceedingto

ulcer,granulomaorcicatricialstenosis,evenmalignancy(tumor).

(2)Obstruction:Itleadstohydronephrosis,andevenimpairmentandloseofrenalfunction.

(3)Infection:renaldamage.

27Urolithiasis:Pathologyand

Pathophysiology

DirectdamageObstructionInfection

Thethreefactorsaboveareinreciprocalcausation.28Hydronephrosisandlesioncausedbythestones29Hydronephrosis,infection,atrophyanddysfunctioncausedbythestones30Renaltumorcausedbystones31Renaltumorcausedbystones32ClinicclassificationofurinarystonesrenalcalculiureteralcalculivesicalcalculiLowerurinarytractstoneurethralcalculiUpperurinarytractstone33

Urolithiasis

Chapter2:

KidneyandUreterStoneDisease

Upperurinarytractcalculiisusuallyformedintherenalcalyx,andthenitlocateintherenalcalyx/pelvisandgrowupgradually.Thecalculicantransferredintotheureter,andstopmostpossiblyinthreeofthebelowpositionswhichisanatomicphysiologicalnarrow:

①Uretero-pelvicjunction②Thesegmentcrossingthe

iliacvessel③Uretero-vesicaljunction

34Urolithiasis

Chapter2KidneyandUreterStoneDiseaseUpperurinarycalculiUnilateralbilateral

Singlemultiple

RoundovalstaghornCompletestaghornincompletestaghorn35KidneyandUreterStone36KidneyandUreterStone37Chapter2

KidneyandUreterStoneDisease1.Clinicalmanifestation

Colic

HematuriaPosition(部位):upperabdomenorlumbarregion.Intensity(程度):beassociatedwiththecalculussite,sizeandshape.Typicalsymptom:renal

colic

.38Urolithiasis

Chapter2

KidneyandUreterStoneDiseaseRenal

colic

Suddenepisodes;Burningpain(絞痛);Persistentpain,withparoxysmalintensification;Radiatedpain(放射痛);

Accompanyingsignsandsymptoms：jactitation,coldsweat,nausea,vomit,urgenturination.39Urolithiasis

Chapter2

KidneyandUreterStoneDisease

Hematuria

Themajorsymptomsismicroscopichematuria,oftenfollowedbypainattack.40Urolithiasis

Chapter2

KidneyandUreterStoneDisease

Urinarycalculi

Itistheassertiveevidenceforurolithiasis,

butonlyfewofpatientsdemonstratethissymptom.41Urolithiasis

Chapter2

KidneyandUreterStoneDisease①Burningpainduringandurination,unusuallyurgentorfrequenturination,andlowerBackpain(irritationsignofbladder)②Pyuria(膿尿)③Oliguriaoranuria④uremia（chronicrenalfailure）⑤abdominaldistension(腹脹)⑥frequencyforbowelmovement⑦lumbarmassOthersymptoms42Urolithiasis

Chapter2

KidneyandUreterStoneDisease

2.Diagnosis

①M(fèi)edicalhistoryandsign

②Laboratorytests

③Imagingexamination43Urolithiasis

Chapter2

KidneyandUreterStoneDisease

Medicalhistoryandsign①HistoryofrenalcolicandHematuria②Historyofcalculous

spontaneouspassage③Anemia（貧血癥）④Tenderpainandpercussionpaininrenalregionsuggestaccompanyinginfectionorobstruction⑤AbdominalandlumbarMass44Urolithiasis

Chapter2

KidneyandUreterStoneDisease

Laboratorytests①Urinalysis(ErythrocyteandLeukocyteinurine);②Urinetesting:24h’sCa2+,P=,UA,OX=,Mg2+;③Bloodbiochemistry:SerumCa2+,P=,Uricacid;④Renalfunctionexamination:BUN,serumcreatinine. 45Urolithiasis

Chapter2

KidneyandUreterStoneDiseaseImagingexamination:①X-rayexamination:Plainfilmofkidney-ureter-bladder(KUB)

IntravenousPyelography(IVP)

RetrogradePyelography(RP)②Ultrasonography③Computerizedtomography(CT)46Urolithiasis

Chapter2

KidneyandUreterStoneDiseaseUltrasonography:①Effectiveexamforscreeningandclinicalfollow-up;

②Toevaluatethedegreeofhydronephrosisandthethicknessofrenalparenchyma;③Toevaluatetherenalbloodflow（RBF）;④Todetecttheradiolucentcalculus;⑤Highsensitivityforrenalcalculus;⑥Lowsensitivityforureteralcalculus;⑦Theimageofsinglelargerenalcalculishowmultiplesmalleronebytheultrasoundscan;⑧False-positive.47

X-rayexamination:Plainfilmofkidney-ureter-bladder(KUB)

Thereismorethan90%ofurinarycalculiwhichcanbedetectedonKUB.

Itisnotedthaturinarycalculishouldbeidentifiedwithcholelithiasis,stercorolith,calcificationofmesentericlymphnode,bovespot,processustransversusvertebrarum'sandpelvicvenousphlebolith,calcificationofarterialwallandthecontaminationcausedbyresidualcontrastmedia.

Disadvantage:

TheradiolucentcalculusareinvisibleonKUB

(thenwhatotherimagingexaminationscanwechosetodetecttheexistenceandlocationofthestones?).

Urolithiasis

Chapter2

KidneyandUreterStoneDisease48Urolithiasis

Chapter2

KidneyandUreterStoneDiseaseX-rayexamination:IntravenousPyelography(IVP)Furthershowingthelocationofcalculus;

Toconfirmtheexistenceofobstructioninurinarytract;Toevaluatetherenalfunction;

Toidentifytheshadowoutsidetheurinarytract.49X-rayexamination:RetrogradePyelography(RP)RPisrecommendedwhen:*ThediagnosisofIVPisindefinite;*Radiolucentcalculus;*Iodineallergy-test(+)碘過敏(positive);*InvisibleofthekidneyonIVPcausedbyrenalinsufficiency.

50Computerized

tomography(CT)*Itistheoreticallyimpossibletobemisdiagnosisofstone;*Ttissensitivetodetecttheradiolucentcalculi;*Itdoesnotneedcontrast-enhancingagent;Itisdifficulttodistinguishthedifferencebetweenlowerureteralcalculiandpelvicvenousphlebolith.Itiscostly.513.DifferentialdiagnosisChronicpyelonephritis(慢性腎盂腎炎)Urothelialneoplasm(尿路腫瘤)lumbarmusclestrain(腰肌勞損)Cholelithiasis(膽石癥)Cholecystitis(膽囊炎)Appendicitis(闌尾炎)52Chapter2

KidneyandUreterStoneDisease:TreatmentTherecommendedtherapiesbaseon:

①thesite,size,shape,numberof

Calculus;

②the

systemiccondition

ofthepatient;

③the

accompanyingcomplications

suchasinfection,obstruction,renalfunction

damage,etc;

toapplydifferentapproaches

forindividualtreatment.IndividualtherapyforstonediseasePatientconditionsSiteofcalculiShapeof

calculiCalculouscomponent

AnatomyfactorsInfectionornoInitialtreatment

Physicalconditions(ARF,CRF,hyperkalemia,severeanemia,hyperglycemia,severeheartdisease,etc)MedicalconditionsThedoctor’sability(open

surgery,URSorPCNL)Medicalequipment

(whatkindofmedicalinstrumentsbeavailable)PatientchoiceThechoicesofthetreatmentisdecidedbyavarietyoffactors54Urolithiasis

Chapter2

KidneyandUreterStoneDiseaseTreatment

:Emergencymanagement

Key：Relievingtherenalcolic(止痛),Relievingtheacuteurinaryretention(尿潴留)Relievingtheuremia(尿毒癥)Controllingtheinfection

Possibleproblems:

①Inadequatepainrelief

②Insufficienthydration

③Overusageofantibiotic

agents

55

Urolithiasis:KidneyandUreterStone

Disease

Treatment

:Conservativetreatment

Indications：diameterofstone<0.6cm,Smoothshape,nourinaryobstructionandinfection.

1、Intakeofplentyofwater(2000ml/d)2、a1-blockers(Tamsolosin);3、Herbaltreatment;

4、tocontrolinfection;

5、theother.56WithdiameterofUreteralstones≥7mm,therateofdischargingautomaticallyisratherlow

2006EUAGUIDELINESONUROLITHIASIS

Urolithiasis:KidneyandUreterStone

Disease

Treatment

:SurgicaltreatmentESWLURSPNLLCopensugeryTheageofMinimallyinvasivetreatmentofUrolithiasisExtracorporealShockWaveLithotripsy,ESWLUreterorenoscopeLithotripsy,URLPercutaneous

Nephrolithotripsy,PNL59Treatment

:

Extracorpealshockwavelithoripsy

（ESWL）

Urolithiasis:KidneyandUreterStone

Disease

HistoryofESWL1969,Gemany,Dornier

corporation1980,Chaussyfirstlyusedintheclinic1984,approvedbyFDA1985,chinasucceededinmanufactureofthismachine70～80%ofstonecasesarenowtreatedbyESWL

61TypesofcrushersBasicstructureiscomposedofTheshockwavegenerator(沖擊波發(fā)生器),thefocusingapparatus(聚焦裝置),Shockwavetransmissionsystem(沖擊波傳播系統(tǒng)),PositioningSystemandcontrolconsole(定位系統(tǒng)及操作臺)●electrohydraulic液電式●Micro-explosive微爆式●electromagnetic電磁式●piezoelectric壓電式

●Shapedconcentrating聚能聚光式

62ESWL63ESWL64Indications(適應(yīng)癥)forESWLKidneystones：Diameter≤

2cmSurfacearea≤

300mm2Surfacearea=Length×width×π×0.25）UreteralstonesBladderstones65ContraindicationsforESWL

禁忌證Gestation(妊娠)Bleedingdisorders(出血性疾病)Acuteurinarytractinfection,UrinarytractactivetuberculosisLowerureteralstonesoccuringinwomenofchildbearingageObstructioninthedistalurinarytractofstonesSevereobesity,severeboneandjointdeformitiesSeriouscardiovascularandcerebrovasculardisease,Patientswithpacemakersarenolongerthecontraindications66FactorsaffectedtheeffectsofESWLStoneclearanceratecanbeupto85%byESWLStonerelated:size,number,location,ingredients,Theretentiontime.

Kidney-related:renalanatomy,renalfunction,drainage.Patient-related:BMI,activity,theamountintakeofdrinkingwater.Crusherand

itsOperation.67Urolithiasis:

KidneyandUreter

StoneDisease

Treatment

:Surgeryprocedure1、Non-opensurgery——Endoscopysurgery①Ureteroscopy②Percutaneous

Nephrolithotomy，PCNL68EndoscopysurgeryProximalureteralstones

近段輸尿管結(jié)石Fortheproximalureteralstonewithdiametergreaterthan1cm，

flexible

ureteroscopyasthefirst-linetreatmentmayhavebettereffect.70

Percutaneous

Nephrolithotomy，PCNL71Opensurgery①輸尿管切開取石（Ureterolithotomy)②腎盂切開取石（Pyetolithotomy）③腎實(shí)質(zhì)切開取石（Nephrolithotomy）④腎部分切除取石（Nephrectomy，partial）

⑤腎切除術(shù)（Nephrectomy）72Opensurgery73Opensurgery74

Principlesofsurgerytreatmentfor★bilateralupperurinarytractstones

1、Ifthereare

bilateraluretercalculi,theoptionistotreatfirstlythemoreseriouslyobstructiveside.However,bilateralstonescanbetreatedsimultaneouslyifconditionsallow.2、Iftherearecalculiexistedinonesideoftheureterandtheothersideofthekidney,ureterstonesshouldbetreatedfirstly.3、Ifcalculiexistedinbothsidesofthekidney,theonewithrelativesimplestoneshouldbetreatedfirstly.4、Whenbilateralupperurinarytractstonesorupperurinarytractstonesinsolitarykidneyleadtoacuteanuria,surgicalprocedureshouldbeperformedimmediatelyifconditionsallow.Ureteralcatheterdrainage,nephrostomyorhemodialysiscanbeappliedtoimproverenalfunctionandthebodyconditionsbeforetheoperationt