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尿 石 症 Urolithiasis

尿 石 症 Urolithiasis. 陈 斌 仁济医院 泌尿外科. 概 述. 有史以来折磨人类最久的疾病之一 最常见的泌尿科疾病之一，男女比约3：1 人们对于该病治疗方法的进展远超越对于病因的了解 90%尿路结石不再采用传统的开放手术 发病有地区性，江南多于江北. 概 况. 形成机制未完全阐明，有多种学说 多数结石无十分理想的预防方法 近年来，肾、输尿管上尿路结石发病率明显提高 如果没有随访及医学干预，尿石症5年内的复发率高达50%. Components of stones.

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尿 石 症 Urolithiasis

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  1. 尿 石 症Urolithiasis 陈 斌 仁济医院 泌尿外科

  2. 概 述 • 有史以来折磨人类最久的疾病之一 • 最常见的泌尿科疾病之一，男女比约3：1 • 人们对于该病治疗方法的进展远超越对于病因的了解 • 90%尿路结石不再采用传统的开放手术 • 发病有地区性，江南多于江北

  3. 概 况 • 形成机制未完全阐明，有多种学说 • 多数结石无十分理想的预防方法 • 近年来，肾、输尿管上尿路结石发病率明显提高 • 如果没有随访及医学干预，尿石症5年内的复发率高达50%

  4. Components of stones • 晶体+基质(crystal+ matrix) 草酸钙、磷酸钙、磷酸镁铵、尿酸、胱氨酸 • 上尿路（肾、输尿管）结石多为草酸钙结石、草酸钙与磷酸钙混合性结石 • 下尿路结石磷酸镁铵、尿酸铵结石多见

  5. 尿石成分及其性质

  6. Etiology Aspects • Extrinsic Factors • Intrinsic Factors • Heredity • Age and Sex • Abnormal metaboly • Local factors

  7. Extrinsic Factors • Climatic and seasonal factors • Water intake • Diet • Medication

  8. Water intake • the volume of water ingested as opposed to that lost by perspiration and respiration • the mineral or trace element content of the water supply of the region

  9. Diet • Protein • Increasing the acid in urine • Hyperuricosuria • Calcium • Hypercalciuria • Hyperoxaluria

  10. Diet • Sodium • Hypercalciuria • Magnesium • Inhibit crystallization of Calcium Phosphate • reduce calcium oxalate crystalloiduria • Vitamins

  11. Medications • Steroids • Vitamins • Sulfanilamide

  12. Abnormal metaboly • Calcium Oxalate Stone • Calcium Phosphate Stone • Uric Acid Stone • Cystine Stone

  13. Calcium Oxalate Stone • Hypercalciuria (excessive calcium in the urine and kidneys) • Absorptive Hypercalciuria • Resorptive Hypercaiciuria • Renal Hypercalciuria

  14. Calcium Oxalate Stone • Hyperoxaluria • Hyperuricosuria • Citrate

  15. Calcium Phosphate Stone • Pure calcium phosphate stone is quite rare • More common in women and are often associated with tubular acidification defects • Showing pure calcium phosphate • Distal renal tubular acidosis • Primary hyperparathyroidism • sarcoidosis

  16. Uric AcidStones • By-product of purine • Typically radiolucent in nature and may not be identified on plain abdominal films • Visible on noncontrast CT images • Associated calcium deposits, may be partially radiopaque

  17. Cystine Stones • Cystine can be found in nerves, muscles, and other body tissues • Cystinuria cause excessive cystine build up in the urine, lead to cystine stones • Occurs in about 1% to 2% of patients with kidney stone disease • The condition often runs in families

  18. Local Factors • Urinary Infection • Urinary Obstruction • Urinary Eyewinker

  19. Local Factors • Urinary Tract Infection 产生解脲酶的细菌-变形杆菌感染 • 尿液中基质增加，促进晶体粘附 • 感染性结石（磷酸镁铵）形成的条件 • pH≥7.2 • 尿中有氨存在

  20. Local Factors • Urinary Obstruction & Anatomic Abnormalities • 近端扩张、尿滞留，尿液浓缩，成石物质过饱和 • 结石近端产生涡流，成石物质沉淀 • 梗阻部位妨碍微石排出 • 尿液滞留继发尿路感染

  21. Local Factors • Urinary Tract Eyewinker 可作为核心诱发成石物质沉淀和附着 • 各种导管、内支架 • 手术时遗留的丝线 • 人为塞入膀胱的金属、木条、塑料

  22. 尿石形成的影响因素 The influencing Factors of Stone Forming

  23. 影响尿路结石形成的因素 • Anatomic Abnormalities • Urinary Tract Infection • Nutrition Status • Others

  24. 成 石 机 制 Pathogenesis

  25. Some Theories • 异质成核学说 • 取向附生学说 • 结石基质学说 • 晶体抑制物质学说

  26. Process • Nucleation (晶核形成) • Crystal Growth (结晶生长) • Crystal Aggregation (结晶聚集) • Crystal Retention (结晶滞留)

  27. Pathogenesis struvite (infection stones) • Made of crystallized magnesium and ammonia phosphate • common acidic by-products of the bacterial breakdown of urea

  28. Pathophysiology • 肾和膀胱内形成结石 • 与结石部位、大小、数目、继发炎症、梗阻程度等有关 • 结石排出过程中，可停留在输尿管和尿道，形成该处结石

  29. Pathophysiology • 肾盏结石阻塞肾盂输尿管连接处或输尿管 • 急性完全性梗阻 • 解除梗阻，可无肾损害 • 慢性不完全性梗阻 • 导致肾积水，影响肾功能 • 较大肾盂结石对肾实质和肾功能损害轻微

  30. Pathophysiology • 输尿管内径自上而下由粗变细-输尿管下1/3处结石最多见 • 进入输尿管，常停留嵌顿于生理狭窄处 • 肾盂输尿管连接处 • 输尿管跨越髂血管处 • 输尿管膀胱连接处

  31. 输尿管肾盂连接处 ureterpelvic junction 越过髂血管处 over the iliac vessels 输尿管膀胱连接处 ureterovesical junction

  32. Pathophysiology • 结石损伤尿路粘膜导致出血、感染 • 梗阻易发生感染 • 感染、梗阻可促使结石形成及长大 • 肾盂及膀胱内结石可引起恶变 • 充满肾盂、部分或全部肾盏：鹿角形结石 (Staghorn)

  33. Pathophysiology 结 石 (stone) 梗阻 感染 (obstruction) (infection)

  34. Suspense If urinary constituents are similar from each kidney and if there is no evidence of obstruction, • Why do most stones present in a unilateral fashion? • Why don't small stones pass uneventfully down the ureter early in their development? • Why do some people form one large stone and others form multiple small calculi?

  35. Question OR Comment?

  36. 上尿路结石 Upper Urinary Tract Calculi

  37. Including Nephrolithiasis and (Kidney Stones) Ureteral Calculi

  38. Types of Stones • calcium salts • struvite (infection stones) • uric acid • cystine

  39. Struvite Stones • Accounts for up 20% of kidney stones • Often occurs in patients who develop urinary tract infections • More common in women • Typically develops as a "staghorn"

  40. Types of Stones - Clinical • Renal Calyx Calculi • Renal Pelvis Calculi • Staghorn Calculi • Upper & Mid Ureter Calculi • Distal Ureter Calculi

  41. Clinical Presentation* • Pain & Hematuria associated with activity • The character of the pain depends on the stone location, size, movement and complication • Renal Colic and noncolicky renal pain are two types of pain originating from kidney • Noncolicky renal pain is caused by distention of the renal capsule

  42. Symptoms & Signs • Renal Colic(肾绞痛) usually is caused by stretching of the collecting system or ureter • Urinary obstruction is the main mechanism responsible for renal colic • Local mechanism such as inflammation, edema, hyperperistalsis may contribute to the perception of pain

  43. Renal (Ureteral) Colic • 肾绞痛 • Comes on suddenly and acutely • Wax and Wane, may be relatively constant • Usually starts in the back, at waist or in the flank, stomach or groin • Nausea, vomiting, chills, fever • Frequently move constantly into unusual position in an attempt to relieve the pain

  44. Renal (Ureteral) Colic • Radiation of pain ： • PUJor upper ureteral tract obstruction 腰部及上腹部，并沿输尿管行经放射至同侧睾丸、阴唇和大腿内侧 • Midureteral obstruction 中下腹，易与急性阑尾炎混淆 • Distal ureter entering vesical, ureteral orifice 伴膀胱刺激症状，尿道/阴茎头放射痛

  45. Radiation of pain with various types of ureteral stone

  46. Radiation of pain with various types of ureteral stone

  47. Radiation of pain with various types of ureteral stone

  48. Hematuria • Blood in the urine - another classic symptom • The blood may be clearly visible, or may be microhematuria • Often, patient’s urine is usually tea-colored and/or cloudy • Microhematuria after movement may be the only one symptom

  49. Symptoms & Signs • 无尿 (anuria) • 双侧上尿路结石引起双侧完全性梗阻 • 独肾上尿路结石完全性梗阻 • 结石伴感染：frequency、dysuria • 继发急性肾盂肾炎或肾积脓 • 畏寒、寒战等全身症状 • 有时感染症状可以是尿路结石唯一表现

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