尿 石 症Urinary Stone Disease
瑞金医院泌尿外科
Urinary Calculi
• The 3rd most common affliction of the urinary tract.
• Exceeded only by urinary tract infections and pathologic conditions of the prostate.
Epidemiology
• Surrouding enviroment : natural, social
• Internal agents : racial inheritance , nutrition , metabolic abnormalities ( cystine , oxalate , calcium&phosphate , uric acid ), acquired diseases ( hyperpara-thyroidism , hypercorticosteronism , gout ), medicines
Stone Formation
• Mechanism :• Only partly identified :
metabolic , infectious
• Most : unknown
Stone Formation
• Requires---supersaturated urine
• ( 1 ) ionic strength
• ( 2 ) urinary PH
• ( 3 ) solute concentration
• ---decrease of inhibitor
Stone Formation
• Anatomical abnormalities
• Urinary infection
• Abnormal calcium&phosphate transfer in renal epithelial cells
Stone Formation
• Nucleation theory: stones originate from crystals or foreign bodies immersed in supersaturated urine.
• Crystal inhibitor theory: calculi form owing to the absence or low concentration of natural stone inhibitors—magnesium, citrate, pyrophosphate( 焦磷酸盐 ), acid glycoprotein
Stone Component
• Crystal : oxalate , phosphate , uric
acid & urate , cystine , xanthine
• Matrix : organic principle 42%~84% , ( 1 )致密的纤维状基质构成同心层(concentric lamina) 结构;( 2 )不定形基质构成凝胶状结构
尿结石晶体成分
尿结石晶体成分
尿结石晶体成分
尿结石晶体成分
尿结石晶体• 密度 : 高 低 草酸钙 磷酸钙 磷酸镁铵 胱氨酸 尿酸
• 硬度 : 高 低 磷酸钙 草酸钙 尿酸 胱氨酸 磷酸镁胺 结石愈硬越易击碎
Ureteral stone protruded from the left ureteral orifice
Single calcium oxalate calculus
Multiple calcium oxalate calculi
Multiple uric acid calculi
Pathophysiology
• Primary pathological changes : renal tubular
lesions , production of stone
matrix , formation of Randall plaques ( 肾钙斑 ).
• Secondary pathological changes : local
mechanical damage , urinary
obstruction , infections , stones combining
with polyps or malignancies.
Clinical Features(Stones at upper urinary tract)
• Pain:
• Renal colic– stretching of the collecting
system or ureter.
• Noncolicky renal pain-- distension of the
renal capsule.
Clinical Features(Stones at upper urinary tract)
• Hematuria
• Infection– pyonephrosis, xanthogranulomatous pyelonephritis
• Associated fever
• Nausea & vomiting
Diagnosis
• History
• Lab Tests : urinalysis , urine culture , serum calcium,phosphate&uric acid , BUN &creatinine
• Radiological investigations :KUB+IVU , ultrasound , CT , retrograde urography
• Endoscopy
IVP
Retrograde Urography
MRU
Renal Calculi
Renal Calculi
Renal Calculi
Renal Calculus
肾结石二维 B 型超声影像图
Ureteral Calculus
输尿管结石二维 B 型超声影像图
Treatment
• Conservative observation : most ureteral calculi pass and do not require interventions.
• Conservative therapy: plenty of water intake, diet, infection control, adjustment of urine PH
• Cystine calculi——alkalinize urine ( PH>7.8 ),D-pencillamine( 青霉胺 ) , -MPG(mercaptopropyonyl glycine) 巯丙基甘氨酸
the traditional Chinese medicine
• 排石冲剂(颗粒):含关木通 (caulis) 成分,内有马兜铃酸 (Aristolochic Acid) ,具备肾毒性。
• 复方金钱草 (lysimachia) 冲剂
Treatment
• Extracoporeal Shock Wave Lithotripsy,
ESWL (体外冲击波碎石)• Endoscopic surgery :• Ureteroscopic ( 输尿管镜 ) stone extraction
• PCNL (Percutaneous nephroscopic
lithotripsy)
• Open surgery: pyelolithotomy,
nephrolithotomy, ureterolithotomy
硬性输尿管镜 软性输尿管镜
钬 激 光 碎 石
开放手术
开放手术
治疗• 双侧上尿路结石手术原则:(相对性)• ( 1 )双侧输尿管结石:梗阻严重一侧• ( 2 )一侧输尿管一侧肾结石:输尿管• ( 3 )双侧肾结石:容易一侧• ( 4 )急性梗阻无尿:立即手术或经皮肾
造瘘
Intervention of Renal Colic
• Antispasmodic therapy:
• atropine, anisodamine, progesterone
• Analgesia:
• pethidine, suppository of indomethacin, procaine
• Combining treatment
Case Report
• 61yr female , recurrent obvious flank pain with high fever 。 Urinalysis WBC++++ , relief after antibiotics therapy.
• Ultrasound: fluid occupation at lower pole of Rt kidney, KUB+IVP : occupation at lower pole of Rt kidney, Rt kidney not visible. Dense plaque located alongside of Rt ureter.
• CT: suspect of multiple renal cysts (Rt).
Final Diagnosis
• Duplicate pelvises & ureters of the right kidney.
• Ureteral stone of the lower Rt ureter with hydronephrosis of the lower renal pelvis.
膀胱结石临床表现
(1) 尿流中断、疼痛 (2) 排尿困难 (3) 尿路刺激症 (4) 感染 (5) 血尿
膀胱结石诊断 (1) 病史 (2) 影像学检查 a 、 X 线检查 b 、 B 超 (3) 膀胱镜检查
膀胱结石治疗
(1) 病原治疗
(2) 经膀胱镜机械、超声、液电、气压 弹道或激光碎石。
(3) 膀胱切开取石术
膀胱结石
膀胱结石
尿道结石继发结石居多一、发生部位 : 前列腺部尿道、尿道舟状窝、 尿道外口。二、临床表现 (1) 疼痛 (2) 排尿困难、尿潴留 (3) 出血、感染
尿道结石三、诊断 (1) 病史 (2) 体检 : 扪诊 (3) 金属尿道探子 (4) 尿道镜 (5)X 线检查 (6)B 超
尿道结石
四、治疗原则 (1) 前尿道结石应尽可能避免尿
道切开取石 (2) 后尿道结石将其推入膀胱后
再按膀胱结石处理
Any comments?
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