尿路结石：泌尿系结石(英文版)

Urolithiasis:UurinaryTractCalculiWhatisUrolithiasis:

Kidneystone(腎結石)

Ureteralstone（輸尿管結石）

Bladderstone（膀胱結石）

Stoneintheurethra（尿道結石）Stoneintheurinarytract:RiskfactorsforstoneformationVarioustypesofstonesCommonsymptomsKnowthedifferenttreatmentoptionsforsiteandsizespecificstonesRecommendationforProphylaxisLearninggoals流行病學及病因學EpidemiologyandEtiology

1.IntrinsicFactors(內源因素)

2.ExtrinsicFactors

（外源因素）EpidemiologyandEtiologyEpidemiologyandEtiologyIntrinsicFactors(1)AgeandSex:5-10%ofgeneralpopulationPeakincidenceage:30-60yearsMenaffected3timesasoftenaswomen(2)Heredity:

cystinuria（胱氨酸尿症）

Familyhistory:3foldriskEpidemiologyandEtiologyIntrinsicFactors（3）Anatomicobstructionandurinarystasis（4）Disease:Urinarytractinfection;Gout;

AbnormalMetabolism/Urinecomposition:

Increasedlevelsofcalcium,oxaluric,uricacidlowlevelofcitricacidEpidemiologyandEtiology

ExtrinsicFactors(1)Geographiclocation

andClimateWarmclimatescausemorefluidlossandincreasedsoluteconcentrationinurine(2)Waterintake

lesswaterintakemayleadtolowurinevolumeandincreasedsoluteconcentrationinurine

EpidemiologyandEtiology

ExtrinsicFactors(3)Lifestyle（生活方式）:occupation(職業),immobility（是否經常運動）

(4)Diet（飲食）: ProteinsthatincreaseuricacidexcretionExcessiveamountsofCarbonicacidbeverage

thatelevateurinaryoxalatelevelLargeintakeofcalciumandoxalate

Whystonesform…Urinebecomessupersaturated（過飽和）…

Majorplayerinmajorityofstones

1.Decreasedurinevolume（低尿量）

2.AbnormalurinepH（異常尿PH值）

3.Absenceofinhibitors（抑制沉積物缺失）

4.Infection（感染）Formationofstonesinvolve3conditionsSlowurineflow低尿流量

–supersaturationofurineDamage

損傷totheliningoftheurinarytract–formcrystalsDecreasedinhibitorsubstances

低抑制物–thatwouldotherwisepreventsupersaturationandcrystalformationExactmechanismofstoneformationremainunclear

Nucleation(晶核形成)CrystalGrowth(結晶生長)CrystalAggregation(結晶聚集)CrystalRetention(結晶滯留)Stone------processStonedevelopmentiscomplexandmultifactorial,Nosingletheorycanaccountforstoneformation

多因素的發病原因

EpidemiologyandEtiology

结石液体摄量和种类摄入肉类的种类和量钙摄入过多或过少水果蔬菜的摄入钠的摄入过多环境因素TypesofStones結石類型Calcium-based（含鈣結石—陽性結石）:~80%ofallstonesCalciumoxalate（草酸鈣結石）

1)Mostcommonstoneformedinindustralizednations2)Mostcommontypeofbladderstone3)Radio-opaque（不透射線的）Calciumphosphate（磷酸鈣結石）TypesofStones2.Non-calcium-based非含鈣結石UricAcid尿酸(8%)Inpureform:radiolucentb.Struvite

鳥糞石(10%)Oftencalled“infectiousstones”c.Cystine

胱氨酸(3%)—hereditaryMoststonesarecomposedofseveralomponents病理生理Pathophysiology—Whatistheeffect?Mostoftheurinarystoneformedinthekidneyandbladder.Thevastmajorityofureteralstoneandurrthralstoneareformedduetothedischargeofthestone.（多數結石形成於腎和膀胱，幾乎所有輸尿管和尿道結石均由上述兩種結石下行後嵌頓形成）PathophysiologyComplications…Hydronephrosis（腎積水）Astonecanlodgeintheureter,obstructurineflowanddilatetheproximalcollectingsystem.Elevatedhydrostaticpressureinthecollectingsystemcanhavedetrimentaleffectsonkidneyfunction…infectionpyelonephritisperinephricabscessurosepsishydroureterhydronephrosisurineextravasationrenalfailureLifelongdisease,afterfirstepisode,stonestendtorecur…（結石復發）At1year15%ofpatientswillgetanotherstoneYear5 50-60%Year10 70–80%StonesareCommon…Pathophysiology

LongstandingstoneInfectionObstructionMetaplasia(組織化生)KidneyfunctionSquamouscellCarcinoma（鱗狀細胞癌）Suspense疑問？

Ifurinaryconstituentsaresimilarfromeachkidneyandifthereisnoevidenceofobstruction:1、Whydomoststonespresentinaunilateralfashion?2、Whydon'tsmallstonespassuneventfullydowntheureterearlyintheirdevelopment?3、Whydosomepeopleformonelargestoneandothersformmultiplesmallcalculi?上尿路結石UpperUrinaryTractCalculiPRESENTATION（症狀）AbdominalorflankPain

（腹痛）RenalColic（腎絞痛）:Sudden;NotRelievedHematuria（血尿）Nausea&vomiting（噁心嘔吐）Chills,fever（寒戰發熱）UppertractcalculusPresentation…(RollingStones)Thecharacterofthepaindependsonthestonelocation,size,movementandcomplication疼痛usuallyiscausedbystretchingofthecollectingsystemorureterUrinaryobstruction—spasm（痙攣）

isthemainmechanismresponsibleforrenalcolicLocalmechanismsuchasinflammation,edema,hyperperistalsis（蠕動亢進）maycontributetotheperceptionofpainRenal(Ureteral)Colic腎絞痛Characteristic—

Renal(Ureteral)Colic腎絞痛Comesonsuddenlyandacutely突發Usuallystartsontheback,atwaistorintheflank,stomachorgroinNausea,vomiting,chills,feverFrequentlymoveintounusualpositioninanattempttorelievethepain轉移性Renal(Ureteral)ColicRadiationofpain（放射痛）：UPJorupperureteraltractobstruction

（腰部及上腹部，並沿輸尿管行經放射至同側睾丸、陰唇和大腿內側）Midureteralobstruction

（中下腹，易與急性闌尾炎混淆）Distalureterenteringvesical,ureteralorifice

（伴膀胱刺激症狀，尿道/陰莖頭放射痛）Hematuria（血尿）

(microscopic鏡下orgross肉眼) -90%ofpatientshavehematuriaonfirstdayofpain -only65%willhavehematuriaondays3and4Bloodintheurine-anotherclassicsymptomThebloodmaybeclearlyvisible,ormaybemicrohematuriaOften,patient’surineisusuallytea-coloredand/orcloudy茶色尿MicrohematuriaaftermovementmaybetheonlyonesymptomHematuria（血尿）Diagnosis（診斷）Stonediagnosis（結石診斷）

includinglocation,size,number,shape,typeComplicationdiagnosis（併發症診斷）UrinaryinfectionDegreeofobstructionRenalfailureEtiologicalevaluation（病因診斷）History（病史）Evaluatethenatureofthepain,includingitsonset;character;potentialradiation;activitiesthatexacerbateoreasethepainAssociatenausea,vomitingGrosshematuriaHistoryofsimilarpainHistoryTypicalrenal,ureteralcolicwithhematuria（腎輸尿管絞痛伴血尿）Riskfactors（危險因素）CrystalluriaDietOccupationandclimateFamilyhistoryMedicationsAbdominalExaminationshouldexcludeothercausesofabdominalpain

（腹部檢查需排除其他引起腹痛的病因）Examinationofabdomenrevealsmoderatedeeptendernessonpalpationoverthelocationofthecalculusandtheareaoftheloin

（結石部位深觸痛）PhysicalExamination（體格檢查）Attemptingtofindreliefinmultiple,frequently,bizarrepositions（患者頻繁更換體位以求減輕疼痛）Tachycardia,sweatingandnausea（心動過速，出汗和噁心）Anabdominalmassmaybepalpableinpatientswithlong-standingobstructiveurinarycalculi&severehydronephrosis（結石長期梗阻嚴重腎積水可觸及腹部或腎區包塊）PhysicalExaminationLaboratoryTest（實驗室檢查）

Urinalysis（尿檢）:Microscopicorgrosshematuria（鏡下或肉眼血尿）

PresentoferythrocyteinthesedimentGrosshematuriamaybetheonlycomplaintPresentofWBC（白細胞）

ModeratepyuriaorpuscellsCulture（細菌培養）

Crystalluria（結晶尿）

LaboratoryTest

Urinalysis（尿檢）:Analysisofurinarymetabolitesin24-hoururinecollections（24小時尿代謝物）Acidifiedsample-Calcium,Oxalate,Magnesium,PhosphorusAlkalinesample–UricacidUntreatedaliquots-Creatinine

Bloodexamination（血液檢查）:Hemoglobin（血紅蛋白）WBCcourt（白細胞計數）Bloodurea（血尿素）Serumcreatinine（血肌酐）Ca,P,Cr,AKP,Uricacid,Albumen,K,Na,Cl,PTH,etcLaboratoryTestLaboratoryTestAnalysisofcalculi（結石分析）Chemicalanalysis（化學分析）–qualitative&semiquantitativeInfraredSpectroscopy（紅外光譜分析）BinocularStereoscopicmicroscope（雙目立體顯微鏡）X-rayDiffraction,ElectronMicroscopy（X線衍射及電鏡）Imagingandoption（影像學檢查）EssentialtoconfirmthesizeandlocationofstoneSeveralOptions

1)Ultrasonography（超聲）

2)KUB（尿路X線平片）

3)IntravenousPyelography(IVP)

（靜脈腎盂造影）

4)NoncontrastHelicalC.T.

（非增強螺旋CT）Ultrasonography(TypeB)（B型超聲）Noninvasivemethodforscreeningurinarystone（無創）Sensitiveindetectingradiolucentcalculiparticularlythosemeasuring2~3mminlargestdimensionsmallstones

（可檢出射線可透結石和2~3mm小結石）Presentinganatomicstructurechangesandhydronephrosis（受解剖結構和腎積水影響）False-positive（假陽性）RadiographicExaminationKUB（泌尿系平片）Morethan95%stoneToosmallornon-calcium結石過小或鈣化程度不高者可不顯示Uricacid純尿酸結石及基質結石可不顯示Lessthan2mm如結石厚度小於2mm則無法分辨Basicmethodforureteralstone是診斷輸尿管結石的最基本方法RadiographicExaminationIVU/IVP（排泄性尿路造影）Kidneystone可確診腎結石Renalfunction腎結構與功能改變Non-opaque透光結石可顯示充盈缺損

notforrenalcolic絞痛發作後2周再做RadiographicExaminationComputerizedTomography(CT)Accurate可分辨0.5mm結石Forallstones可顯示任何成分的結石Especiallyforureteralstone螺旋CT可檢出90%輸尿管結石,輸尿管結石表現為高密度影及“框邊”DIFFERENTIALDiagnosis

（鑒別診斷）GynecologicProcesses

異位妊娠heterotopicpregnancy卵巢囊腫扭轉ovariancysttorsionAppendicitis（闌尾炎）Cholecystitis（膽囊炎）Hernia（疝）Aneurysm（動脈瘤）Tumors（腫瘤）Treatment（治療）Dependson:

Stonelocation（結石位置）

Stoneburden（結石大小）

Kidneyfunction（腎功能）Availabilityofskill（術者技術）Availabilityofinstrument（器械）Treatment—

Conservativetreatment(保守治療)

Indication:stonediameterislessthan0.6cm,andsmooth,therearenoobstructionandinfection.Uricacidorcystinestone.（結石<6cm,光滑，無尿路梗阻、無感染，純尿酸結石和胱氨酸結石）1)

intakemorewater—important（增加水攝入）2)

regulatingfood（飲食管理）3)

controllinginfection（控制感染）1.Acute:treatpain,infection,obstructionNarcotics,forfluids—IVandpo,strainurine2.Evaluatecauseofstoneformation:history,stoneanalysis

a.Adequatehydration,

dietaryNA+restriction,dietarychanges,medicationb.Treatmentofstruvitestones:controlofinfectionTreantment——MedicalManagement（藥物治療）Treatment—CalculiRemoval（取石）IndicationsforCalculiRemoval（指征）:1)Stonestoolargeforspontaneouspassage（無法自行排出的結石）2)Stonesassociatedwithbacteriuriaorsymptomaticinfection（感染）3)Stonescausingimpairedrenalfunction（腎功能不全）4)Stonescausingpersistentpain,nausea,orileus（腸梗阻）5)Inabilityofpatienttobetreatedmedically（無法藥物治療）6)Patientwithonekidney（孤立腎）Treatment—CalculiRemoval（取石）1.Extracorporealshock-wavelithotripsy(ESWL)2.InvasiveLithotripsy

Ureteroscopy

PercutaneousNephrolithotomyLaparoscopy3.OpenoperationTreatment—ESWL

Open?NearlyNOPCNLRetrogadeureterscopicvisulazationofthedesiredcalyxofentrycanbeusedtofacilitatepercutaneousaccessWhy?-PCNL(經皮腎鏡取石術)operativeprinciple—bilateraluppertractcalculus(雙側上尿路結石手術原則）a.bilateralureterolith:severeobstructivesidefirst（雙側輸尿管結石：先處理梗阻嚴重側）b.

unilateralureterolithandcontralateralrenalstone:urterolithfirst（一側輸尿管結石伴對側腎結石：先處理輸尿管結石）a.

protectingkidney(保護腎功能為前提)b.

easyandsafesidefirst（先取易取側）c.ifrenalfunctiondecreases,severeobstructionorgeneralconditionispoor,nephrostomyfirst,waitingforthebettercondition.（腎功能極差，梗阻嚴重，全身情況不良，先行經皮腎造瘺）operativeprinciple—bilateralrenalstonegeneralconditionpermitted,operateimmediately.Ifthegeneralconditionistoobadtoperformoperation,we’dbetterdonephrostomy.（立即行取石術。如全身情況不允許，輸尿管插管或經皮腎造瘺）operativeprinciple—solitarykidneystoneandanuriacausedbybilateraluppertractstone(孤立腎結石或雙側上尿路結石梗阻致無尿)膀胱結石BladderStoneBladderstoneClinicalPresentation（臨床表現）

Typicalsymptom：（排尿突然中斷，疼痛放射至遠端尿道，伴排尿困難和膀胱刺激征）

Acuteurinaryretentionassociatedwithsevereperineum/rectumpain.Painmayradiatetothetipofthepenis.IntermittenturinarystreamTerminalhematuria&infection(終末血尿及感染)Bladderstone1)Ultrasonograph