2015结石1

EAU2015版结石诊疗指南,西安交通大学第一附属医院泌尿外科 陈兴发,Key changes for the 2015 publication,In pregnant women, ultrasound is the imaging method of choice. In pregnant women, MRI should be used as a second-line imaging modality. In pregnant women, low-dose CT should be considered as a last-line option. The exposure should be less than 0.05 Gy.,If renal stones are not treated, periodic valuation is recommended (after 6 months and yearly thereafter),Radiolucent stones may be dissolvableFor ureterolithotomy, laparoscopy is recommended for large impacted stones when endoscopic lithotripsy or SWL has failed.UTIs must be excluded or treated prior to endourologic stone removal. In all patients undergoing endourologic treatment, perioperative antibiotic prophylaxis is recommended.,In myelomeningocele patients, latex allergy is common, thus appropriate measures need to be taken regardless of the treatment. For surgical interventions, general anesthesia remains the only option.Horseshoe kidneys Acceptable stone free rates can be achieved with flexible ureteroscopy,肾绞痛的治疗,首选双氯芬酸（扶他灵）和消炎痛 次选氢吗啡醇、镇痛新和曲蚂多。 受体阻滞剂(坦索罗辛）可降低肾绞痛的复发。 对输尿管结石导致肾绞痛急诊SWL可作为一 线治疗。 A combination of alkalinisation with tamsulosin seems to achieve the highest SFRs for distal ureteral stones,结石观察,结石的大小、位置与和患者意愿都是影响和决定是否取石的因素：新诊断输尿管小于10mm结石不在取石范围的患者，可定期观察，药物排石。,已稳定6个月的无症状肾盏结石，是取石和继续观察仍有争议，当出现结石生长、重新形成梗阻、感染、急或慢性疼痛应治疗。,药物排石治疗,由于文献比较应用a-受体阻滞剂坦索罗辛与钙离子通道拮抗剂硝苯地平治疗远端输尿管结石引起肾绞痛，坦索罗辛更有效缓解肾绞痛，促进输尿管结石排出，推荐使用-受体阻滞剂药物排石而钙通道拮抗剂不再推荐。,药物排石治疗,由于文献比较应用a-受体阻滞剂坦索罗辛与钙离子通道拮抗剂硝苯地平治疗远端输尿管结石引起肾绞痛，坦索罗辛更有效缓解肾绞痛，促进输尿管结石排出，推荐使用-受体阻滞剂药物排石而钙通道拮抗剂不再推荐。a-受体阻滞剂坦索罗辛可减轻留置双J管相关的症状和提高患者耐受性 SWL和URS术后应用a-受体阻滞剂可改善残石清除率。,无管化,Nephrostomy and stents,presence of residual stones; likelihood of a second-look procedure; significant intraoperative blood loss; urine extravasation; ureteral obstruction; potential persistent bacteriuria due to infected stones; solitary kidney; bleeding diathesis; planned percutaneous chemolitholysis,Ureterorenoscopy (URS),Contraindications Apart from general considerations, e.g. with general anaes-thesia or untreated UTIs, URS can be performed in all patients without any specific contraindications.,The use of UAS improves vision by establishing a continuous outflow, decrease intrarenal pressure and potentially reduce operating time.,Stenting before and after URSPre-stenting facilitates ureteroscopic management of stones, improves the stone-free rate, and reduces complications. Following URS, stents should be inserted in patients who are at increased risk of complications.,Indications for open surgery,Complex stone burdenTreatment failure of SWL and/or PNL, or URSIntrarenal anatomical abnormalities: infundibular stenosis; stone in the calyceal diverticulum (particularly in an anterior calyx); obstruction of the ureteropelvic junction; and stricture if endourologic procedures have failed or are not promising Morbid obesity Skeletal deformity, contractures and fixed deformities of hips and legs Comorbidity,Indications for open surgery,Concomitant open surgery Non-functioning lower pole (partial nephrectomy), non-functioning kidney (nephrectomy) Patient choice ( after failed minimally invasive procedures, a single procedure avoiding the risk of multiple PNL procedures might be preffered by the case) Stone in an ectopic kidney where percutaneous access and SWL may be difficult or impossible For the paediatric population, the same considerations apply as for adults,Indications for laparoscopic kidney-stone surgery include:,Complex stone burden Failed previous SWL and/or endourological procedures Anatomical abnormalities Morbid obesity Nephrectomy in case of non-functioning kidney.,Indications for laparoscopic ureteral stone surgery include:,large, impacted stones;multiple ureteral stones;in cases of concurrent conditions requiring surgery;when other non-invasive or low-invasive procedures have failed.,Indications for active removal of ureteral stones,- Stones with low likelihood of spontaneous passage.- Persistent pain despite adequate analgesic medication. Persistent obstruction. Renal insufficiency (renal failure, bilateral obstruction, or single kidney).,Indications for active removal of kidney stones,- Stone growth.- Stones in high-risk patients for stone formation.- Obstruction caused by stones.- Infection.- Symptomatic stones (e.G., Pain or haematuria).- Stones 15 mm.- Stones 2 cm) may be treated with flexible URS. However, in that case there is a higher risk that a follow-up procedure and placement of a ureteral stent may be needed.For the lower pole, PNL or RIRS is recommended, even for stones 1.5 cm, because the efficacy of SWL is limited (depending on favourable and unfavourable factors for SWL).,肾下盏结石治疗选择,SWL治疗肾下盏结石的清除率较低，15mm的结石治疗推荐PNL或RIRS 。SWL治疗时应考虑影响碎石成功的因素，不利因素包括难粉碎结石（一水草酸钙、磷酸氢钙、胱氨酸结石）；下盏漏斗部与肾盂之间的夹角为锐角；下盏长度10mm；漏斗部宽度5mm。,输尿管结石治疗选择,In patients with newly diagnosed small ureteral stones, if active removal is not indicated, observation with periodic evaluation is an optional initial treatment.Appropriate medical therapy should be offered to these patients to facilitate stone passagSeveral trials have demonstrated an -blocker class effect on stone expulsion rates.,If insertion of a flexible URS is difficult, prior rigid ureteroscopy can be helpful for optical dilatation. If ureteral access is not possible, insertion of a JJ stent followed by URS after 7-14 days offers an alternative procedure.,URS后需留置双J管：ureteral trauma, residual fragments, bleeding, perforation, UTIs, or pregnancy and in all doubtful cases. 输尿管损伤，残石，出血，穿孔，感染，妊娠和特殊病例,The ideal duration of stenting is not known. Most urologists favour 1-2 weeks after URS.Alpha-blockers reduce the morbidity of ureteral stents and increase tolerability,Selection of procedure for active removal of ureteral stones,For ureterolithotomy, laparoscopy is recommended for large impacted stones when endoscopic lithotripsy