Слайд 2
![Urinary calculi are the third most common affliction of the](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-1.jpg)
Urinary calculi are the third most common affliction of the urinary
tract, exceeded only by urinary tract infections and pathologic conditions of the prostate.
Слайд 3
![The nomenclature associated with urinary stone disease arises from a variety of disciplines. .](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-2.jpg)
The nomenclature associated with urinary stone disease arises from a variety
of disciplines. .
Слайд 4
![Before the time of von Struve, the stones were referred](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-3.jpg)
Before the time of von Struve, the stones were referred to
as guanite, because magnesium ammonium phosphate is prominent in bat droppings.
Слайд 5
![The history of the nomenclature associated with urinary stone disease](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-4.jpg)
The history of the nomenclature associated with urinary stone disease is
as intriguing as that of the development of the interventional techniques used in their treatment.
Слайд 6
![Urinary stones have plagued humans since the earliest records of](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-5.jpg)
Urinary stones have plagued humans since the earliest records of civilization.
The etiology of stones remains speculative.
Слайд 7
![Advances in the surgical treatment of urinary stones have outpaced our understanding of their etiology.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-6.jpg)
Advances in the surgical treatment of urinary stones have outpaced our
understanding of their etiology.
Слайд 8
![Without such follow-up and medical intervention, stone recurrence rates can](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-7.jpg)
Without such follow-up and medical intervention, stone recurrence rates can be
as high as 50% within 5 years.
Слайд 9
![Renal & Ureteral Stones Etiology Theories to explain urinary stone disease are incomplete.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-8.jpg)
Renal & Ureteral Stones
Etiology
Theories to explain urinary stone disease are incomplete.
Слайд 10
![Renal & Ureteral Stones Etiology Stone formation requires supersaturated urine.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-9.jpg)
Renal & Ureteral Stones
Etiology
Stone formation requires supersaturated urine. Supersaturation depends on
urinary pH, ionic strength, solute concentration, and complexation.
Слайд 11
![Renal & Ureteral Stones Etiology The activity coefficient reflects the availability of a particular ion.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-10.jpg)
Renal & Ureteral Stones
Etiology
The activity coefficient reflects the availability of a
particular ion.
Слайд 12
![Renal & Ureteral Stones Etiology Concentrations above this point are](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-11.jpg)
Renal & Ureteral Stones
Etiology
Concentrations above this point are metastable and are
capable of initiating crystal growth and heterogeneous nucleation.
Слайд 13
![Renal & Ureteral Stones Etiology Multiplying 2 ion concentrations reveals](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-12.jpg)
Renal & Ureteral Stones
Etiology
Multiplying 2 ion concentrations reveals the concentration product.
The concentration products of most ions are greater than established solubility products.
Слайд 14
![Renal & Ureteral Stones Etiology Crystal formation is modified by](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-13.jpg)
Renal & Ureteral Stones
Etiology
Crystal formation is modified by a variety of
other substances found in the urinary tract, including magnesium, citrate, pyrophosphate, and a variety of trace metals.
Слайд 15
![Renal & Ureteral Stones Etiology The nucleation theory suggests that](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-14.jpg)
Renal & Ureteral Stones
Etiology
The nucleation theory suggests that urinary stones originate
from crystals or foreign bodies immersed in supersaturated urine.
Слайд 16
![Renal & Ureteral Stones Etiology Additionally, many stone formers' 24-h](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-15.jpg)
Renal & Ureteral Stones
Etiology
Additionally, many stone formers' 24-h urine collections are
completely normal with respect to stone-forming ion concentrations.
Слайд 17
![Renal & Ureteral Stones Etiology This theory does not have](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-16.jpg)
Renal & Ureteral Stones
Etiology
This theory does not have absolute validity since
many people lacking such inhibitors may never form stones, and others with an abundance of inhibitors may, paradoxically, form them.
Слайд 18
![Crystal Component Stones are composed primarily of a crystalline component.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-17.jpg)
Crystal Component
Stones are composed primarily of a crystalline component.
Crystals of
adequate size and transparency are easily identified under a polarizing microscope.
Слайд 19
![Crystal Component Multiple steps are involved in crystal formation, including nucleation, growth, and aggregation.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-18.jpg)
Crystal Component
Multiple steps are involved in crystal formation, including nucleation, growth,
and aggregation.
Слайд 20
![Crystal Component A crystal of one type thereby serves as](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-19.jpg)
Crystal Component
A crystal of one type thereby serves as a nidus
for the nucleation of another type with a similar crystal lattice.
Слайд 21
![Crystal Component How these early crystalline structures are retained in](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-20.jpg)
Crystal Component
How these early crystalline structures are retained in the upper
urinary tract without uneventful passage down the ureter is unknown.
The theory of mass precipitation or intranephronic calculosis suggests that the distal tubules or collecting ducts, or both, become plugged with crystals, thereby establishing an environment of stasis, ripe for further stone growth.
Слайд 22
![Crystal Component This explanation is unsatisfactory; tubules are conical in](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-21.jpg)
Crystal Component
This explanation is unsatisfactory; tubules are conical in shape and
enlarge as they enter the papilla, thereby reducing the possibility of ductal obstruction.
Слайд 23
![Crystal Component The fixed particle theory postulates that formed crystals](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-22.jpg)
Crystal Component
The fixed particle theory postulates that formed crystals are somehow
retained within cells or beneath tubular epithelium. Randall noted whitish-yellow precipitations of crystalline substances occurring on the tips of renal papillae as submucosal plaques.
Слайд 24
![Crystal Component These can be appreciated during endoscopy of the upper urinary tract.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-23.jpg)
Crystal Component
These can be appreciated during endoscopy of the upper urinary
tract.
Слайд 25
![Matrix Component The amount of the noncrystalline, matrix component of](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-24.jpg)
Matrix Component
The amount of the noncrystalline, matrix component of urinary stones
varies with stone type, commonly ranging from 2% to 10% by weight.
Слайд 26
![Matrix Component Histologic inspection reveals laminations with scant calcifications.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-25.jpg)
Matrix Component
Histologic inspection reveals laminations with scant calcifications.
Слайд 27
![Matrix Component The role of matrix in the initiation of](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-26.jpg)
Matrix Component
The role of matrix in the initiation of ordinary urinary
stones as well as matrix stones is unknown.
Слайд 28
![Urinary Ions Calcium Calcium is a major ion present in urinary crystals.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-27.jpg)
Urinary Ions
Calcium
Calcium is a major ion present in urinary crystals.
Слайд 29
![Diuretic medications may exert a hypocalciuric effect by further decreasing calcium excretion.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-28.jpg)
Diuretic medications may exert a hypocalciuric effect by further decreasing calcium
excretion.
Слайд 30
![Oxalate Oxalate is a normal waste product of metabolism and is relatively insoluble.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-29.jpg)
Oxalate
Oxalate is a normal waste product of metabolism and is relatively
insoluble.
Слайд 31
![Oxalate Once absorbed from the small bowel, oxalate is not](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-30.jpg)
Oxalate
Once absorbed from the small bowel, oxalate is not metabolized and
is excreted almost exclusively by the proximal tubule.
Слайд 32
![Oxalate Normal excretion ranges from 20 to 45 mg/d and does not change significantly with age.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-31.jpg)
Oxalate
Normal excretion ranges from 20 to 45 mg/d and does not
change significantly with age.
Слайд 33
![Oxalate Hyperoxaluria may develop in patients with bowel disorders, particularly](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-32.jpg)
Oxalate
Hyperoxaluria may develop in patients with bowel disorders, particularly inflammatory bowel
disease, small-bowel resection, and bowel bypass.
Слайд 34
![Oxalate The unbound oxalate is readily absorbed.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-33.jpg)
Oxalate
The unbound oxalate is readily absorbed.
Слайд 35
![Phosphate Phosphate is an important buffer and complexes with calcium in urine.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-34.jpg)
Phosphate
Phosphate is an important buffer and complexes with calcium in urine.
Слайд 36
![Phosphate The small amount of phosphate filtered by the glomerulus](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-35.jpg)
Phosphate
The small amount of phosphate filtered by the glomerulus is predominantly
reabsorbed in the proximal tubule.
Слайд 37
![Uric Acid Uric acid is the by-product of purine metabolism.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-36.jpg)
Uric Acid
Uric acid is the by-product of purine metabolism. The pH
of uric acid is 5.75.
Слайд 38
![Uric Acid Rarely, a defect in xanthine oxidase results in](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-37.jpg)
Uric Acid
Rarely, a defect in xanthine oxidase results in increased levels
of xanthine; the xanthine may precipitate in urine, resulting in stone formation.
Слайд 39
![Uric Acid This results from a deficiency of adenine phosphoribosyltransferase (APRT).](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-38.jpg)
Uric Acid
This results from a deficiency of adenine phosphoribosyltransferase (APRT).
Слайд 40
![Sodium Although not identified as one of the major constituents](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-39.jpg)
Sodium
Although not identified as one of the major constituents of most
urinary calculi, sodium plays an important role in regulating the crystallization of calcium salts in urine.
Слайд 41
![Sodium This reduces the ability of urine to inhibit calcium oxalate crystal agglomeration.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-40.jpg)
Sodium
This reduces the ability of urine to inhibit calcium oxalate crystal
agglomeration.
Слайд 42
![Citrate Citrate is a key factor affecting the development of calcium urinary stones.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-41.jpg)
Citrate
Citrate is a key factor affecting the development of calcium urinary
stones.
Слайд 43
![Citrate Metabolic stimuli that consume this product (as with intracellular](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-42.jpg)
Citrate
Metabolic stimuli that consume this product (as with intracellular metabolic acidosis
due to fasting, hypokalemia, or hypomagnesemia) reduce the urinary excretion of citrate.
Слайд 44
![Magnesium Dietary magnesium deficiency is associated with an increased incidence of urinary stone disease.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-43.jpg)
Magnesium
Dietary magnesium deficiency is associated with an increased incidence of urinary
stone disease.
Слайд 45
![Magnesium The exact mechanism whereby magnesium exerts its effect is undefined.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-44.jpg)
Magnesium
The exact mechanism whereby magnesium exerts its effect is undefined.
Слайд 46
![Sulfate Urinary sulfates may help prevent urinary calculi. They can complex with calcium.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-45.jpg)
Sulfate
Urinary sulfates may help prevent urinary calculi. They can complex with
calcium.
Слайд 47
![Stone Varieties](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-46.jpg)
Stone Varieties
Слайд 48
![Calcium Calculi Calcifications can occur and accumulate in the collecting](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-47.jpg)
Calcium Calculi
Calcifications can occur and accumulate in the collecting system, resulting
in nephrolithiasis.
Eighty to eighty-five percent of all urinary stones are calcareous.
Слайд 49
![Calcium Calculi Hyperuricosuria is identified as a solitary defect in](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-48.jpg)
Calcium Calculi
Hyperuricosuria is identified as a solitary defect in 8% of
patients and associated with additional defects in 16%.
Слайд 50
![Calcium Calculi Finally, decreased urinary citrate is found as an](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-49.jpg)
Calcium Calculi
Finally, decreased urinary citrate is found as an isolated defect
in 17% of patients and as a combined defect in an additional 10%.
Слайд 51
![Calcium Calculi Symptoms are secondary to obstruction, with resultant pain,](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-50.jpg)
Calcium Calculi
Symptoms are secondary to obstruction, with resultant pain, infection, nausea,
and vomiting, and rarely culminate in renal failure.
Слайд 52
![Calcium Calculi Most patients with nephrolithiasis, however, do not have obvious nephrocalcinosis.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-51.jpg)
Calcium Calculi
Most patients with nephrolithiasis, however, do not have obvious nephrocalcinosis.
Слайд 53
![Calcium Calculi Nephrocalcinosis may result from a variety of pathologic states.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-52.jpg)
Calcium Calculi
Nephrocalcinosis may result from a variety of pathologic states.
Слайд 54
![Calcium Calculi Disease processes resulting in bony destruction, including hyperparathyroidism,](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-53.jpg)
Calcium Calculi
Disease processes resulting in bony destruction, including hyperparathyroidism, osteolytic lesions,
and multiple myeloma, are a third mechanism. Finally, dystrophic calcifications forming on necrotic tissue may develop after a renal insult.
Слайд 55
![Absorptive Hypercalciuric Nephrolithiasis Normal calcium intake averages approximately 900-1000 mg/d.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-54.jpg)
Absorptive Hypercalciuric Nephrolithiasis
Normal calcium intake averages approximately 900-1000 mg/d.
Слайд 56
![Absorptive Hypercalciuric Nephrolithiasis This results in an increased load of calcium filtered from the glomerulus.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-55.jpg)
Absorptive Hypercalciuric Nephrolithiasis
This results in an increased load of calcium filtered
from the glomerulus.
Слайд 57
![Absorptive Hypercalciuric Nephrolithiasis Absorptive hypercalciuria can be subdivided into 3 types.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-56.jpg)
Absorptive Hypercalciuric Nephrolithiasis
Absorptive hypercalciuria can be subdivided into 3 types.
Слайд 58
![Absorptive Hypercalciuric Nephrolithiasis Urinary calcium excretion returns to normal values with therapy.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-57.jpg)
Absorptive Hypercalciuric Nephrolithiasis
Urinary calcium excretion returns to normal values with therapy.
Слайд 59
![Symptoms & Signs at Presentation](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-58.jpg)
Symptoms & Signs at Presentation
Слайд 60
![Symptomatology Pain Hematuria Pyuria](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-59.jpg)
Symptomatology
Pain
Hematuria
Pyuria
Слайд 61
![12% of men and 5% of women will suffer from](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-60.jpg)
12% of men and 5% of women will suffer from renal
stones by the age of 70 years.
Слайд 62
![The majority of patients with nephrolithiasis are those from 25 up to 55 years.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-61.jpg)
The majority of patients with nephrolithiasis are those from 25 up
to 55 years.
Слайд 63
![By localization there can be stones of the: -Calices -](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-62.jpg)
By localization there can be stones of the:
-Calices
-
Слайд 64
![Upper-tract urinary stones usually eventually cause pain. The character of the pain depends on the location.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-63.jpg)
Upper-tract urinary stones usually eventually cause pain.
The character of the
pain depends on the location.
Слайд 65
![Radiation of pain with various types of ureteral stone.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-64.jpg)
Radiation of pain with various types of ureteral stone.
Слайд 66
![Upper right: Midureteral stone. Same as above but with more pain in the lower abdominal quadrant.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-65.jpg)
Upper right: Midureteral stone. Same as above but with more pain
in the lower abdominal quadrant.
Слайд 67
![Pain Renal colic and noncolicky renal pain are the 2](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-66.jpg)
Pain
Renal colic and noncolicky renal pain are the 2 types of
pain originating from the kidney.
Слайд 68
![Pain This pain is due to a direct increase in intraluminal pressure, stretching nerve endings.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-67.jpg)
Pain
This pain is due to a direct increase in intraluminal pressure,
stretching nerve endings.
Слайд 69
![Pain Renal colic does not always wax and wane or](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-68.jpg)
Pain
Renal colic does not always wax and wane or come in
waves like intestinal or biliary colic but may be relatively constant.
Слайд 70
![Pain In the ureter, however, local pain is referred to](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-69.jpg)
Pain
In the ureter, however, local pain is referred to the distribution
of the ilioinguinal nerve and the genital branch of the genitofemoral nerve, whereas pain from obstruction is referred to the same areas as for collecting system calculi (flank and costovertebral angle), thereby allowing discrimination.
Слайд 71
![Pain The vast majority of urinary stones present with the](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-70.jpg)
Pain
The vast majority of urinary stones present with the acute onset
of pain due to acute obstruction and distention of the upper urinary tract.
Слайд 72
![Pain The stone burden does not correlate with the severity](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-71.jpg)
Pain
The stone burden does not correlate with the severity of the
symptoms. Small ureteral stones frequently present with severe pain, while large staghorn calculi may present with a dull ache or flank discomfort.
Слайд 73
![Pain The pain frequently is abrupt in onset and severe](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-72.jpg)
Pain
The pain frequently is abrupt in onset and severe and may
awaken a patient from sleep.
Слайд 74
![Pain This movement is in contrast to the lack of](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-73.jpg)
Pain
This movement is in contrast to the lack of movement of
someone with peritoneal signs; such a patient lies in a stationary position.
Слайд 75
![Renal Calyx Stones or other objects in calyces or caliceal](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-74.jpg)
Renal Calyx
Stones or other objects in calyces or caliceal diverticula may
cause obstruction and renal colic.
Слайд 76
![Renal Calyx Radiographic imaging may not reveal evidence of obstruction](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-75.jpg)
Renal Calyx
Radiographic imaging may not reveal evidence of obstruction despite the
patient's complaints of intermittent symptoms.
Слайд 77
![Renal Calyx Caliceal calculi occasionally result in spontaneous perforation with urinoma, fistula, or abscess formation.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-76.jpg)
Renal Calyx
Caliceal calculi occasionally result in spontaneous perforation with urinoma, fistula,
or abscess formation.
Слайд 78
![Renal Calyx Effective long-term treatment requires stone extraction and elimination of the obstructive component.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-77.jpg)
Renal Calyx
Effective long-term treatment requires stone extraction and elimination of the
obstructive component.
Слайд 79
![Renal Pelvis Stones in the renal pelvis > 1 cm](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-78.jpg)
Renal Pelvis
Stones in the renal pelvis > 1 cm in diameter
commonly obstruct the ureteropelvic junction, generally causing severe pain in the costovertebral angle, just lateral to the sacrospinalis muscle and just below the 12th rib.
Слайд 80
![Renal Pelvis Symptoms frequently occur on an intermittent basis following](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-79.jpg)
Renal Pelvis
Symptoms frequently occur on an intermittent basis following a drinking
binge or consumption of large quantities of fluid.
Слайд 81
![Renal Pelvis Partial or complete staghorn calculi that are present](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-80.jpg)
Renal Pelvis
Partial or complete staghorn calculi that are present in the
renal pelvis are not necessarily obstructive.
Слайд 82
![Upper and Mid Ureter Pain associated with ureteral calculi often](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-81.jpg)
Upper and Mid Ureter
Pain associated with ureteral calculi often projects to
corresponding dermatomal and spinal nerve root innervation regions.
Слайд 83
![Upper and Mid Ureter The pain of upper ureteral stones](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-82.jpg)
Upper and Mid Ureter
The pain of upper ureteral stones thus radiates
to the lumbar region and flank.
Слайд 84
![Upper and Mid Ureter Stones or other objects in the](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-83.jpg)
Upper and Mid Ureter
Stones or other objects in the upper or
mid ureter often cause severe, sharp back (costovertebral angle) or flank pain.
Слайд 85
![Distal Ureter Calculi in the lower ureter often cause pain](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-84.jpg)
Distal Ureter
Calculi in the lower ureter often cause pain that radiates
to the groin or testicle in males and the labia majora in females.
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![Distal Ureter Stones in the intramural ureter may mimic cystitis,](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-85.jpg)
Distal Ureter
Stones in the intramural ureter may mimic cystitis, urethritis, or
prostatitis by causing suprapubic pain, urinary frequency and urgency, dysuria, stranguria, or gross hematuria.
Bowel symptoms are not uncommon.
In women the diagnosis may be confused with menstrual pain, pelvic inflammatory disease, and ruptured or twisted ovarian cysts.
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![Distal Ureter Strictures of the distal ureter from radiation, operative](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-86.jpg)
Distal Ureter
Strictures of the distal ureter from radiation, operative injury, or
previous endoscopic procedures can present with similar symptoms.
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![Hematuria A complete urinalysis helps to confirm the diagnosis of](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-87.jpg)
Hematuria
A complete urinalysis helps to confirm the diagnosis of a urinary
stone by assessing for hematuria and crystalluria and documenting urinary pH.
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![Infection Magnesium ammonium phosphate (struvite) stones are synonymous with infection stones.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-88.jpg)
Infection
Magnesium ammonium phosphate (struvite) stones are synonymous with infection stones.
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![Infection All stones, however, may be associated with infections secondary](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-89.jpg)
Infection
All stones, however, may be associated with infections secondary to obstruction
and stasis proximal to the offending calculus.
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![Infection Uropathogenic bacteria may alter ureteral peristalsis by the production of exotoxins and endotoxins.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-90.jpg)
Infection
Uropathogenic bacteria may alter ureteral peristalsis by the production of exotoxins
and endotoxins.
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![Infection Local inflammation from infection can lead to chemoreceptor activation](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-91.jpg)
Infection
Local inflammation from infection can lead to chemoreceptor activation and perception
of local pain with its corresponding referral pattern.
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![Pyonephrosis Presentation is variable and may range from asymptomatic bacteriuria](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-92.jpg)
Pyonephrosis
Presentation is variable and may range from asymptomatic bacteriuria to florid
urosepsis. Bladder urine cultures may be negative.
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![Pyonephrosis Radiographic investigations are frequently nondiagnostic.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-93.jpg)
Pyonephrosis
Radiographic investigations are frequently nondiagnostic.
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![Pyonephrosis If unrecognized and untreated, pyonephrosis may develop into a renocutaneous fistula.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-94.jpg)
Pyonephrosis
If unrecognized and untreated, pyonephrosis may develop into a renocutaneous fistula.
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![Xanthogranulomatous Pyelonephritis Xanthogranulomatous pyelonephritis is associated with upper-tract obstruction and infection.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-95.jpg)
Xanthogranulomatous Pyelonephritis
Xanthogranulomatous pyelonephritis is associated with upper-tract obstruction and infection.
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![Xanthogranulomatous Pyelonephritis Open surgical procedures, such as a simple nephrectomy](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-96.jpg)
Xanthogranulomatous Pyelonephritis
Open surgical procedures, such as a simple nephrectomy for minimal
or nonrenal function, can be challenging owing to marked and extensive reactive tissues.
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![Associated Fever Costovertebral angle tenderness may be marked with acute](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-97.jpg)
Associated Fever
Costovertebral angle tenderness may be marked with acute upper-tract obstruction;
however, it cannot be relied on to be present in instances of long-term obstruction.
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![Associated Fever If retrograde manipulations are unsuccessful, insertion of a percutaneous nephrostomy tube is required.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-98.jpg)
Associated Fever
If retrograde manipulations are unsuccessful, insertion of a percutaneous nephrostomy
tube is required.
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![Nausea and Vomiting Effective ureteral peristalsis requires coaptation of the](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-99.jpg)
Nausea and Vomiting
Effective ureteral peristalsis requires coaptation of the ureteral walls
and is most effective in a euvolemic state.
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![Special Situations Pregnancy Renal colic is the most common nonobstetric](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-100.jpg)
Special Situations
Pregnancy
Renal colic is the most common nonobstetric cause of acute
abdominal pain during pregnancy.
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![Special Situations Pregnancy The increased filtered load of calcium, uric](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-101.jpg)
Special Situations
Pregnancy
The increased filtered load of calcium, uric acid, and sodium
from the 25-50% increase in glomerular filtration rate associated with pregnancy has been thought to be a responsible factor in stone development.
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![Special Situations Pregnancy Initial investigations can be undertaken with renal](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-102.jpg)
Special Situations
Pregnancy
Initial investigations can be undertaken with renal ultrasonography and limited
abdominal x-rays with appropriate shielding.
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![Special Situations Pregnancy Treatment requires balancing the safety of the](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-103.jpg)
Special Situations
Pregnancy
Treatment requires balancing the safety of the fetus with the
health of the mother.
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![Obesity Ultrasound examination is hindered by the attenuation of ultrasound beams.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-104.jpg)
Obesity
Ultrasound examination is hindered by the attenuation of ultrasound beams.
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![Obesity Standard lithotripters have focal lengths less than 15 cm](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-105.jpg)
Obesity
Standard lithotripters have focal lengths less than 15 cm between the
energy source and the F2 target, frequently making treatment of obese patients impossible.
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![Obesity A preplaced heavy suture eases removal of such sheaths.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-106.jpg)
Obesity
A preplaced heavy suture eases removal of such sheaths.
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![Obesity Postoperative prophylaxis for thromboembolic complications should be considered.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-107.jpg)
Obesity
Postoperative prophylaxis for thromboembolic complications should be considered.
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![There are numerous theories of origination and development of urolithiasis,](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-108.jpg)
There are numerous theories of origination and development of urolithiasis, however,
any of them does not explain completely its origin.
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![The known role in the etiology of urolithiasis is played](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-109.jpg)
The known role in the etiology of urolithiasis is played by
the disturbance of urate, phosphate, oxalic exchange, however, it is not to be overestimated.
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![It is possible to divide the numerous factors contributing to](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-110.jpg)
It is possible to divide the numerous factors contributing to the
formation of stones, into exogenous and endogenic, and the latter into general and local (connected directly with changes in the kidney).
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![The formation of phosphate stones is promoted also by fractures of tubular bones.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-111.jpg)
The formation of phosphate stones is promoted also by fractures of
tubular bones.
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![The uric acid is the end product of purine exchange.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-112.jpg)
The uric acid is the end product of purine exchange.
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![To the internal causes, contributing to originating urolithiasis, we also](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-113.jpg)
To the internal causes, contributing to originating urolithiasis, we also attribute
disturbance of a normal function of the gastrointestinal tract (chronic gastritis, colitis, peptic ulcer).
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![The local factors of lithogenesis](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-114.jpg)
The local factors of lithogenesis
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![70-80% of all stones are Ca containing. The major factor](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-115.jpg)
70-80% of all stones are Ca containing. The major factor in
urolithiasis in children and adults is the production of insoluble calcium salts of oxalic acid.
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![Three conditions which contribute to the formation of struvite stones are the following: Congenital anomalies](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-116.jpg)
Three conditions which contribute to the formation of struvite stones are
the following:
Congenital anomalies
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![There are four types of urate urolithiasis: Idiopathic urate urolithiasis](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-117.jpg)
There are four types of urate urolithiasis:
Idiopathic urate urolithiasis
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![Formation of stones of uric acid depends on: pH of urine](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-118.jpg)
Formation of stones of uric acid depends on:
pH of urine
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![Anatomical Pathology Degree of obstruction of the urinary paths Expressiveness](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-119.jpg)
Anatomical Pathology
Degree of obstruction of the urinary paths
Expressiveness of inflammatory process,
which, as a rule, accompanies the disease
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![Complications of urolithiasis The most often complication of nephrolithiasis is](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-120.jpg)
Complications of urolithiasis
The most often complication of nephrolithiasis is the inflammatory
process in the kidney, that may clinically proceed in the acute or chronic form.
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![Both chronic pyelonephrosis and pyonephrosis, as well as hydronephrosis owing](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-121.jpg)
Both chronic pyelonephrosis and pyonephrosis, as well as hydronephrosis owing to
urolithiasis can entail a nephrogenic arterial hypertention.
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![The most severe complication of urolithiasis is prerenal anuria with the development of acute renal failure.](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-122.jpg)
The most severe complication of urolithiasis is prerenal anuria with the
development of acute renal failure.
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![Diagnostics The diagnosis of urolithiasis is established, first of all,](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-123.jpg)
Diagnostics
The diagnosis of urolithiasis is established, first of all, on the
basis of the patient’s complaints and anamnesis.
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![Laboratory research It is necessary to remember, that the absence](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-124.jpg)
Laboratory research
It is necessary to remember, that the absence of pathological
changes of urine does not allow to eliminate nephrolithiasis, as the stone can desely obturate the urinary paths, and the investigated urine is excreted from a contralateral kidney.
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![Ultrasound investigation](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-125.jpg)
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![X-ray examination](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-126.jpg)
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![Retrograde ureteropyelography](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-127.jpg)
Retrograde ureteropyelography
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![Computed tomography](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-128.jpg)
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![Differential diagnosis](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-129.jpg)
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![Treatment](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-130.jpg)
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![Conservative treatment](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-131.jpg)
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![Indications for surgical intervention: Urinary obstructions with progressing damage of](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-132.jpg)
Indications for surgical intervention:
Urinary obstructions with progressing damage of the kidney
Persistent
infection despite antibiotics
Uncontrollable pain
Impairment of renal function
A relapsing gross hematuria
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![Instrumental methods of treatment](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-133.jpg)
Instrumental methods of treatment
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![Percutaneous nephrolithotomy](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-134.jpg)
Percutaneous nephrolithotomy
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![Extracorporeal shock wave lithotripsy (ESWL)](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/406394/slide-135.jpg)
Extracorporeal shock wave lithotripsy (ESWL)