外科学课件：泌尿系结石(英文版)-

UrolithiasisEpidemiology3:1M:F(~7%men/3%women)3rd-5thdecademostcommon(70%)Hereditarypredisposition(RTAtype1,Hyper-parathyroidism,cysteinuria,milk-alkalisyndrome,sarcoidosis,Crohn'sdisease)EpidemiologyClimate(mountainous,desert,ortropical)Timeofyear(warmestthreemonths)Lifestyle(sedentary)Medications:proteaseinhibitors,carbonicanhydraseinhibitors,laxatives,triamterenePatientCharacteristics<16yearoldcomprise7%ofcases1:1M:FCauses:metabolicabnormalities50%,urologicalabnormalities20%,infection15%,immobilization5%1/3haverecurrencewithin1year50%within5yearsPathophysiologyFormationrequiresthreekeyelementsSupersaturationofurinewithsolutesRelativelackoftheinhibitorscitrate&pyrophosphateStasisorlackofurineflowComposition:75%calciumoxalate10%staghorncalculi(struvite):associatedwithurease-splittingbacteria,poorAb.penetrationandusuallyrequiresurgeryUricacidstones10%(Radiolucent!!!)PlacesforobstructionObstructionleadsto:Rapidredistributionofrenalbloodflow

,↓glomerularfiltrationrate

renalexcretionshiftstounaffectedkidneyObstructionleadsto:CausesrapiddecreaseinureteralperistalticactivityCompleteobstructionmayleadtolossofrenalfunctionIncreasedoccurrenceofirreversibledamageafter1to2weeksofobstructionPartialobstructionlowerlikelihoodofrenalinjury,maystillresultinirreversibledamage.Criticalsize5mm~90%<5mmandlocatedinthelowerureterpassspontaneously15%passifbetween5and8mm95%>8mmbecomeimpactedgenerallyrequiringlithotripsyorsurgicalremoval75%ofstonesarelocatedinthedistalthirdoftheureterClinicallyUsuallyasymptomaticuntilobstructsacuteonsetseverepain,typicallyatrestTypicallyflank,abdomenwithreferraltoipsilaterallabiaortesticleMaybewrithinginpain,reluctanttoliestillEpisodicaspasses,painfreeuntilobstructsmoredistallyCausesofpainColicky,severeflankpain:hyperperistalsisofsmoothmuscleofthecalyces,pelvis,andureterDullache:attributedtoacuteobstructionandrenalcapsulartensionColickyUrinarypH

pH>7.6suspiciousforurea-splittingorganismsbecausethekidneywillnot,undernormalconditions,produceurineinthisalkalinerange.pH<5oftenassociatedwiththeformationofuricacidcalculi.

LABORATORYUrineAnalysishematuriasupportsdiagnosis,absentin15%;crystalsseenw/wostonesLABORATORYDipstickdetectsheme,myoglobinandporphyrins,needmicro(seeRBCs)BUN&CreatinineespeciallyifimagingwithRCM,higherratesofcomplicationsinDM>1.5,CRF>2.5Imagingperformedwithafirstepisodeofrenalcolic.Otherindications:DiagnosisisunclearThoseinwhomaproximalUTI,inadditiontoacalculus,issuspected.AKUBisthestandard,initialradiographdonebeforeinjectingcontrastmediaduringIVP.ImagingStaghornCalculusIVPshowingobstructed,dilatedleftureterandcollectingsystem

BUSImagingViewofpelvisshowsradiopaquecalculus.

Smallcalcification(arrow),suspectedforureteralstone.ImagingStaghorncalculusinrightrenalpelvisUreteralstone(arrowheads)inrightpelviswithperiureteralstrandingImaging“staghorn”stoneinCTUStonegonewildinfectionoccasionallyoccursinthepresenceofanobstructivestone.Ahistoryoffeverandchillsstronglysuggestssuperimposedinfectionandisaurologicemergency.ItisimperativetodoanIVPoranultrasoundstudyinthesecasesSterilepyuriastronglysuggestsrenaltuberculosis;confirmationacid-fastbacilliDifferentialDiagnosisAorticdissection,abdominalaorticaneurysm

Appendicitis:usuallydon’tseerebound,guarding,distentionwithstoneInfectious:feverwithCVA,considerpyelonephritisPapillarynecrosis:DM,SCD,NSAIDabuse;seeHematuriaandpyuriaVascular:Renalveinthrombosis,MesentericischemiaGynecologicalTREATMENTPaincontrol:OpiodsandnsaidsNSAIDs:analgesic,decreaseureterospasmandrenalcapsularpressurebydiminishingGFRintheobstructedkidney.ObstructionwithInfection:UrologyemergencyLithotomyTREATMENTESWL=ExtracorporealShock-WaveLithotripsyTREATMENT“StoneStreet”complicatedfromESWLTREATMENTPCNL=PerCutaneousNephroLithotomy

TREATMENTlaserlithotrityviaureterscopy

Bladderstonesdifferentfromrenalstonesalmostexclusivelyelderlymenmostoftencompl