尿-石-症课件.ppt

1、尿尿 石石 症症Urinary Stone Disease瑞金医院泌尿外科瑞金医院泌尿外科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，metabo

2、lic abnormalities（cystine，oxalate，calcium&phosphate，uric acid），acquired diseases（hyperpara-thyroidism，hypercorticosteronism，gout），medicinesStone Formation Mechanism： Only partly identified：metabolic，infectious Most： unknownStone Formation Requires-supersaturated urine （1）ionic strength （2）urinary PH

3、 （3）solute concentration -decrease of inhibitorStone Formation Anatomical abnormalities Urinary infection Abnormal calcium&phosphate transfer in renal epithelial cellsStone Formation Nucleation theory: stones originate from crystals or foreign bodies immersed in supersaturated urine. Crystal inhibit

4、or theory: calculi form owing to the absence or low concentration of natural stone inhibitorsmagnesium, citrate, pyrophosphate(焦磷酸盐), acid glycoproteinStone 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；（

5、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 密度密度:高高 低低 草酸钙草酸钙 磷酸钙磷酸钙 磷酸镁铵磷酸镁铵 胱氨酸胱氨酸 尿酸尿酸 硬度硬度:高高 低低 磷酸钙磷酸钙 草酸钙草酸钙 尿酸尿酸 胱氨酸胱氨酸 磷酸镁胺磷酸镁胺 结石愈硬越易击碎结石愈硬越易击碎Ureteral stone protruded from the left ureteral orificeSingle calcium oxalate calculusMultiple calcium oxalate calculiMultiple uric acid calculi

6、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 urin

7、ary 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 & vomitingDiagnosis History

8、 Lab Tests：urinalysis，urine culture，serum calcium,phosphate&uric acid，BUN &creatinine Radiological investigations：KUB+IVU，ultrasound，CT，retrograde urography EndoscopyIVPRetrograde UrographyMRURenal CalculiRenal CalculiRenal CalculiRenal Calculus肾结石二维肾结石二维B型超声影像图型超声影像图Ureteral Calculus输尿管结石二维输尿管结石二维B

9、型超声影像图型超声影像图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 calculialkalinize urine（PH7.8），D-pencillamine(青霉胺)，-MPG(mercaptopropyonyl glycine)巯丙基甘氨酸th

10、e 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: pyelolithotom

11、y, nephrolithotomy, ureterolithotomy硬性输尿管镜软性输尿管镜钬钬 激激 光光 碎碎 石石开放手术开放手术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 indomet

12、hacin, 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 loca

13、ted 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. 膀胱结石膀胱结石临床表现临床表现 (1) (1) 尿流中断、疼痛尿流中断、疼痛 (2) (2) 排尿困难排尿困难 (3) (3) 尿路刺激症尿路刺激症 (4)

14、(4) 感染感染 (5) (5) 血尿血尿膀胱结石膀胱结石诊断诊断 (1) (1) 病史病史 (2) (2) 影像学检查影像学检查 a a、 X X线检查线检查 b b、 B B超超 (3) (3) 膀胱镜检查膀胱镜检查膀胱结石膀胱结石治疗治疗 (1)(1)病原治疗病原治疗 (2)(2)经膀胱镜机械、超声、液电、气压经膀胱镜机械、超声、液电、气压 弹道或激光碎石。弹道或激光碎石。 (3)(3)膀胱切开取石术膀胱切开取石术膀胱结石膀胱结石膀胱结石膀胱结石尿道结石尿道结石继发结石居多继发结石居多一、发生部位一、发生部位: :前列腺部尿道、尿道舟状窝、前列腺部尿道、尿道舟状窝、 尿道外口。尿道外口。二、临床表现二、临床表现 (1)(1)疼痛疼痛 (2)(2)排尿困难、尿潴留排尿困难、尿潴留 (3)(3)出血、感染出血、感染尿道结石尿道结石三、诊断三、诊断 (1)(1)病史病史 (2)(2)体检体检: :扪诊扪诊 (3)(3)金属尿道探子金属尿道探子 (4)(4)尿道镜尿道镜 (5)X(5)X线检查线检查 (6)B(6)B超超尿道结石尿道结石四、治疗原则四、治疗原则 (1)(1)前尿道结石应尽可能避免前尿道结石应尽可能避免尿道切开取石尿道切开取石 (2)(2)后尿道结石将其推入膀胱后尿道结石将其推入膀胱后再按膀胱结石处理后再按膀胱结石处理Any comments?