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URINARY STONE DISEASE DEPARTMENT OF UROLOGY IAŞI – 2013.

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Presentation on theme: "URINARY STONE DISEASE DEPARTMENT OF UROLOGY IAŞI – 2013."— Presentation transcript:

1 URINARY STONE DISEASE DEPARTMENT OF UROLOGY IAŞI – 2013

2 INTRODUCTION 3rd most common condition of the urinary tract (1 – UTIs, 2 – prostate diseases) stone recurrence rates – 50% within 5 years !

3 RENAL & URETERAL ETIOLOGY composition = crystals + organic matrix (2-10%) supersaturated urine stone formation urinary pH ionic strength (concentration of monovalent ions) solute concentration (concentration of 2 ions, solubility product, formation product) complexation (Na – oxalate, sulfate – Ca) inhibitors (magnesium, citrate, pyrophosphate, trace metals) nucleation theory – crystals or foreign bodies immersed in supersaturated urine crystal inhibitor theory – absence or low concentration of natural stone inhibitors

4 RENAL & URETERAL nucleation (heterogeneous – epitaxy !), growth & aggregation stone formation retention in the upper urinary tract (nephrocalcinosis !) mass precipitation theory (intranephronic calculosis) fixed particle theory – Randall plaques, Carr corpuscles matrix calculi – previous kidney surgery & chronic UTIs STONE VARIETIES Calcium Calculi (80-85%) absorptive hypercalciuria – Ca absorption Ca filtered (glomerulus) PTH tubular reabsorption of Ca Ca ur resorptive hypercalciuria – primary hyperparathyroidism (parathyroid adenoma) P ur, P sr Ca sr, Ca ur renal damage Ca ur

5 RENAL & URETERAL renal hypercalciuria – intrinsic renal tubular defect in calcium excretion Ca ur Ca sr PTH (secondary) Ca resorbtion (bone) & absorption (gut) Ca ur hyperuricosuria hyperoxaluria – primary or enteric (inflammatory bowel disease) hypocitraturia – metabolic acidosis, hypokalemia (thiazide therapy), fasting, hypomagnesemia, androgens, UTI Noncalcium Calculi struvite – magnesium, ammonium and phosphate uric acid cystine – autosomal recessive xanthine, indinavir, silicate, triamterene

6 RENAL & URETERAL SYMPTOMS & SIGNS AT PRESENTATION Pain renal colic noncolicky renal pain Hematuria Infection – pyonephrosis, xanthogranulomatous pyelonephritis Fever, Anuria !, Nausea and Vomiting EVALUATION Risk Factors – crystalluria, socioeconomic factors, diet, occupation, climate, family history, medications Physical Examination Imaging Investigations – US, KUB film, IVU, CT (noncontrast spiral), retrograde pyelography, nuclear scintigraphy

7 RENAL & URETERAL Differential Diagnosis – acute appendicitis, ectopic pregnancies, twisted ovarian cysts, diverticular disease, bowel obstruction, biliary stones, peptic ulcer disease, acute renal artery embolism, abdominal aortic aneurysm etc. INTERVENTION Conservative Observation – spontaneous passage! Dissolution Agents – oral alkalinizing agents (sodium or potassium bicarbonate and potassium citrate), i.v. alkalinization (sodium lactate), intrarenal alkalinization (sodium bicarbonate) – acidification – hemiacidrin (Renacidin) Relief of Obstruction – JJ ureteral stent, PNS

8 RENAL & URETERAL ESWL (Extracorporeal Shock Wave Lithotripsy) electrohydraulic, piezoceramic, electromagnetic approximately 75% of patients with renal calculi (< cm) treated with ESWL become stone-free in 3 months

9 RENAL & URETERAL Ureteroscopic Stone Extraction highly efficacious for lower ureteral calculi stone-free rates range from % lithotrites – electrohydraulic, ultrasonic, laser, pneumatic

10 RENAL & URETERAL Percutaneous Nephrolithotomy choice for large (> 2 cm) calculi, those resistant to ESWL, select lower pole calyceal stones and instances with evidence of obstruction Remaining calculi can be retrieved with flexible endoscopes, additional percutaneous puncture access, follow-up irrigations, ESWL, or additional percutaneous sessions

11 RENAL & URETERAL Open Stone Surgery pyelolithotomy anatrophic nephrolithotomy radial nephrotomy nephrectomy ureterolithotomy

12 BLADDER manifestation of an underlying pathologic condition, including voiding dysfunction (urethral stricture, BPH, bladder neck contracture, neurogenic bladder) or a foreign body irritative voiding symptoms, intermittent urinary stream, urinary tract infections, hematuria, or pelvic pain US electrohydraulic, ultrasonic, laser, pneumatic and mechanical lithotrites cystolithotomy


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