外科学课件泌尿系结石英文版VIP免费

UrolithiasisEpidemiology3:1M:F(~7%men/3%women)3rd-5thdecademostcommon(70%)Hereditarypredisposition(RTAtype1,Hyper-parathyroidism,cysteinuria,milk-alkalisyndrome,sarcoidosis,Crohn'sdisease)EpidemiologyClimate(mountainous,desert,ortropical)Timeofyear(warmestthreemonths)Lifestyle(sedentary)Medications:proteaseinhibitors,carbonicanhydraseinhibitors,laxatives,triamterenePatientCharacteristics<16yearoldcomprise7%ofcases1:1M:FCauses:metabolicabnormalities50%,urologicalabnormalities20%,infection15%,immobilization5%1/3haverecurrencewithin1year50%within5yearsPathophysiologyFormationrequiresthreekeyelements1.Supersaturationofurinewithsolutes2.Relativelackoftheinhibitorscitrate&pyrophosphate3.Stasisorlackofurineflow•Composition:1.75%calciumoxalate2.10%staghorncalculi(struvite):associatedwithurease-splittingbacteria,poorAb.penetrationandusuallyrequiresurgery3.Uricacidstones10%(Radiolucent!!!)PlacesforobstructionObstructionleadsto:Rapidredistributionofrenalbloodflow,↓glomerularfiltrationraterenalexcretionshiftstounaffectedkidneyObstructionleadsto:CausesrapiddecreaseinureteralperistalticactivityCompleteobstructionmayleadtolossofrenalfunctionIncreasedoccurrenceofirreversibledamageafter1to2weeksofobstructionPartialobstructionlowerlikelihoodofrenalinjury,maystillresultinirreversibledamage.Criticalsize5mm~90%<5mmandlocatedinthelowerureterpassspontaneously15%passifbetween5and8mm95%>8mmbecomeimpactedgenerallyrequiringlithotripsyorsurgicalremoval75%ofstonesarelocatedinthedistalthirdoftheureterClinicallyUsuallyasymptomaticuntilobstructsacuteonsetseverepain,typicallyatrestTypicallyflank,abdomenwithreferraltoipsilaterallabiaortesticleMaybewrithinginpain,reluctanttoliestillEpisodicaspasses,painfreeuntilobstructsmoredistallyCausesofpainColicky,severeflankpain:hyperperistalsisofsmoothmuscleofthecalyces,pelvis,andureterDullache:attributedtoacuteobstructionandrenalcapsulartensionColickyUrinarypHpH>7.6suspiciousforurea-splittingorganismsbecausethekidneywillnot,undernormalconditions,produceurineinthisalkalinerange.pH<5oftenassociatedwiththeformationofuricacidcalculi.LABORATORYUrineAnalysishematuriasupportsdiagnosis,absentin15%;crystalsseenw/wostonesLABORATORYDipstickdetectsheme,myoglobinandporphyrins,needmicro(seeRBCs)BUN&CreatinineespeciallyifimagingwithRCM,higherratesofcomplicationsinDM>1.5,CRF>2.5Imagingperformedwithafirstepisodeofrenalcolic.Otherindications:–Diagnosisisunclear–ThoseinwhomaproximalUTI,inadditiontoacalculus,issuspected.AKUBisthestandard,initialradiographdonebeforeinjectingcontrastmediaduringIVP.ImagingStaghornCalculusIVPshowingshowingobstructed,dilatedleftobstructed,dilatedleftureterandcollectingureterandcollectingsystemsystemBUSImagingViewofpelvisshowsradiopaquecalculus.Smallcalcification(arrow),suspectedforureteralstone.ImagingStaghorncalculusinrightrenalpelvisUreteralstone(arrowheads)inrightpelviswithperiureteralstrandingImaging“staghorn”stoneinCTUStonegonewildinfectionoccasionallyoccursinthepresenceofanobstructivestone.Ahistoryoffeverandchillsstronglysuggestssuperimposedinfectionandisaurologicemergency.ItisimperativetodoanIVPoranultrasoundstudyinthesecasesSterilepyuriastronglysuggestsrenaltuberculosis;confirmationacid-fastbacilliDifferentialDiagnosisAorticdissection,abdominalaorticaneurysmAppendicitis:usuallydon’tseerebound,guarding,distentionwithstoneInfectious:feverwithCVA,considerpyelonephritisPapillarynecrosis:DM,SCD,NSAIDabuse;seeHematuriaandpyuriaVascular:Renalveinthrombosis,MesentericischemiaGynecologicalTREATMENTPaincontrol:OpiodsandnsaidsNSAIDs:analgesic,decreaseureterospasmandrenalcapsularpressurebydiminishingGFRintheobstructedkidney.ObstructionwithInfection:UrologyemergencyLithotomyTREATMENTESWL=ExtracorporealShock-WaveLithotripsyTREATMENT“StoneStreet”complicatedfromESWLTREATMENTPCNL=PerCutaneousNephroLithotomyTREATMENTlaserlithotrityviaureterscopyBladderstonesdifferentfromrenalstonesalmostexclusivelyelderlymenmostoftencomplicationofotherurologicdisease.TheothercommonindwellingcatheterMaycomplainofsuddeninterruptionoftheurinarystream.Thisstronglysuggestsavesicalstonethatintermittentlyobstructsthebladderoutlet膀胱結石KUB提示膀胱結石