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RENAL CALCULIand ESWL ndPNL

الكلية كلية الطب     القسم  الجراحة     المرحلة 4
أستاذ المادة محمد رضا جودي عبود جلو       05/01/2017 04:24:09
RENAL CALCULI
Etiology:
Many theories, the current opinion:
1. Dietetic:
Vit. A deficiency, desquamation, the cell will be the nidus for the stone.
2. Altered urinary solutes and colloid:
Dehydration increases the conc. Of urinary solutes, may precipitate. And reduction of urinary colloid which adsorb solutes, or mucoprotein which chelate calcium, may result in crystal and stone formation.
3. Decrease urinary citrate: that important to calcium phosphate in solution (soluble).
4. Renal infection: stone common with infection, because change in urine PH.
5. Inadequate urinary drainage and urinary stasis.
6. Prolong immobilization: as paraplegia.
7. Hyperparathyroidism:
Increase mobilization of calcium from the bone to blood then to urine.


Types of renal calculi:
1. Oxalate stone (calcium oxalate stone): irregular with sharp projection causing bleeding. Radio dense.
2. Phosphate calculus: calcium phosphate often with ammonium magnesium phosphate (struvie) smooth, grow in infected urine (alkaline) may become big (stag horn), and may silent. Radio opaque.

3. Uric acid urate calculi: hard yellow, multiple, radiolucent if pure, but most of it mix with calcium so faint radiological shadow.

4. Cystine calculus: uncommon with congenital error of metabolism that leads to cystinuria.pink or yellow change to greenish color when exposed to air. Radio opaque because they contain sulphur, hard.

5. Xanthine calculus: rare smooth round. (Autosomal recessive), radiolucent.

Clinical Feature:
Common, between 30-50 years, male/female 4:3.
SILENT CALCULI: even large stag horn may no symptom but progressing renal damage, and uremia may be, if bilateral renal; stone.
PAIN: is the leading symptom in 75%, pain the renal angle, hypochondrium, ureteric colic is agonizing pain, from the loin to groin. It is sudden, colic in nature, it radiate to groin, penis, labium, as stone progressing down to ureter, the severity not related to the size of the stone, may associated with hematuria. There is tenderness on deep bimanual exam. And rarely rigidity of lateral abdominal muscle.
HAEMATURIA: may leading symptoms, may microscopic haematuria.
PYURIA: infection is likely, and become dangerous when the kidney is obstructed, septicemia can quickly develop.
The mechanical effect of stones irritating the urothelium may cause pyuria even in the absence of infection.
Investigation of suspected urinary stone disease:
1. Radiology:
KUB (kidney, ureter, bladder): radio opaque stone only seen about 85% of stone.
2. Contrast-enhanced computerized tomography:
CT scan (spiral) is the mainstay of investigation for acute ureteric colic.
3. Excretory urography:
To see the site of the stone and the anatomy of the urinary system, and some information about the function of the kidney.
4. Ulrasound scanning:
Is the of the most value in locating the stone.

Surgical treatment of urinary calculi:
1: conservative:
In stone smaller than 0.5 cm, pass spontaneously, unless associated infection so intervention indicated, so antibiotics started immediately, surgical treatment include minimally invasive technique, sometime open surgery may needed.
2. Modern methods of stone removal of kidney stone:
Percutaneouse nephrolithotomy (PNL):
By creating a port to renal calyx or pelvis using special technique through the skin guided by fluoroscopy or ultrasound , the using nephroscopy through this tract ,to disintegrate the stone using ultrasonic or pneumatic or laser lithotripters for distraction of the stone and remove the gravel through the same tract .
Indication for PNL:
1. urinary obstruction not caused by stone: stone in calcial diverticulum,uretro pelvic stenosis.
2 .large volume stone more than 3 cm (staghorn stones).
3. Stone that can t be positioned within the focus of the shock wave: due to abnormalities of urinary system or skeleton or stone in transplanted kidney, or when high weight.
4. Lower pole calcial stone even less than 2-3 cm.
Post op complication may include intra operative and post operative hemorrhage, infection, incomplete removal of the stone in some cases that may need post op. ESWL. , sometime injury to adjacent organ as colon or pleura.

Extracorporeal shock wave lithotripsy ( ESWL): the stone bombarded with shock wave of sufficient energy to disintegrate into fragment, the shock wave are generated by a source external to the body and propagated into the body and then focused on a kidney stone.
The generators include:
1. Electrohydrolic.
2. Electromagnatic.
3. Piezoelectric.
The shock wave should transmitted through water because it become poor when transmit through the air so use bath of water or bag of water.
Localization of the stone controlled by: 1.fluoroscopic imaging (using X ray).
2. Ultrasonic imaging.
The complication of ESWL include: renal colic, infection, haematuria, and ecchymosis, sometime subcapsular hematoma of the kidney.
Preoperative physical examination should be thorough as in preparation for any surgery, blood pressure is important, body habitus if any gross skeletal abnormalities, contracture or excessive weight may preclude ESWL.
Pregnant lady and patient with large abdominal aorta aneurysim, or uncorrectable bleeding disorder should not be treated with ESWL. If patient with cardiac pacemaker we may need cardiologist monitoring.
The most important complication is steinstrasse (Stone Street) or culmination of stone gravel in a ureter causing obstruction and may need uretroscopy management.
Open surgery for renal calculi:
Including: pyelolithotomy: extract the stone through renal pelvis
Extended pyelolithotomy by extracting the stone through a wide incision extending to the calyces.
Nephrolithotomy: through the renal parenchyma.

PREVENTION:
ALL THE STONE FORMER SHOULD BE INVESTIGATED.
In recurrent stone:
1. Serum calcium, to exclude hyperparathyroidism.
2. Serum uric acid.
3. 24 urine for urate calcium, and phosphate.
4. stone analysis.

Dietary advice is not usually helpful, unless proved metabolic error, example calcium oxalate better to be moderate in eat milk product, spinach, asparagus…..
Hyperuricaemia: ovoid red meat offal, fish, and treated with allopurinol.
Restriction of eggs meat and fish rich in sulpher should be restricted in cystin urea.

Drink a plenty of water which is very important in all type of stone.
Drug treatment is largely ineffective except in idiopathic hypercalciuria.
:

By:
Assist. Professor
M.R.Judi


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