Uurolithiasis is a chronic disease characterized by metabolic disorders with the formation of stones in the kidneys and urinary tract, formed from the constituents of urine. This is one of the most common kidney and urinary tract diseases. Urolithiasis (Kidney Stone Disease – KSD) is diagnosed in 32-40% of all urological pathologies, and ranks second after infectious and inflammatory diseases.
KSD is detected at any age, however, most often in working age (20-55 years). In childhood and old age, cases of primary detection are very rare. Men get sick 3 times more often than women, but staghorn stones are most often found in women (up to 70%). In most cases, stones form in one of the kidneys, but in 9-17% of cases, urolithiasis is bilateral.
CAUSES OF URINOSIS DISEASE
Currently there is no unified theory of the causes of the development of urolithiasis. Urolithiasis is a multifactorial disease, has complex, diverse development mechanisms and various chemical forms. The main mechanism of the disease is considered to be congenital – a metabolic disorder, which leads to the formation of insoluble salts that form into stones. However, even if there is a congenital predisposition to urolithiasis, it will not develop if there are no predisposing factors.
According to their chemical composition, urinary stones are divided into oxalates, phosphates, urates, carbonates, less common are cystine, xanthine, protein, and cholesterol stones. The number of stone-forming minerals does not exceed three; other minerals may be found as impurities. The stones also contain organic substances. Stones, as a rule, have a layered structure; can be single or multiple.
THE FOLLOWING METABOLIC DISORDERS ARE THE BASIS OF THE FORMATION OF URINARY STONES:
- hyperuricemia (increased levels of uric acid in the blood)
- hyperuricuria (increased levels of uric acid in urine)
- hyperoxaluria (increased levels of oxalate salts in the urine)
- hypercalciuria (increased levels of calcium salts in the urine)
- hyperphosphaturia (increased levels of phosphate salts in the urine)
- change in urine acidity
In the occurrence of these metabolic changes, some authors give preference to environmental influences (exogenous factors), others – to endogenous causes, although their interaction is often observed.
EXOGENIC CAUSES OF UROLITHIASIS:
- climate
- geological structure of the soil
- chemical composition of water and flora
- food and drinking regimen
- living conditions (monotonous, sedentary lifestyle and recreation)
- working conditions (hazardous industries, hot shops, hard physical labor, etc.).
Food and drinking regimes of the population – the total calorie content of food, abuse of animal protein, salt, foods containing large amounts of calcium, oxalic and ascorbic acids, lack of vitamins A and group B in the body – play a significant role in the development of KSD.
ENDOGENOUS CAUSES OF UROLITHIASIS:
- infections of both the urinary tract and outside the urinary system (tonsillitis, furunculosis, osteomyelitis, salpingoophoritis)
- metabolic diseases (gout, hyperparathyroidism)
- deficiency, absence or hyperactivity of a number of enzymes
- severe injuries or illnesses associated with prolonged immobilization of the patient
- diseases of the digestive tract, liver and biliary tract
- hereditary predisposition to urolithiasis
- factors such as gender and age play a certain role in the genesis of urolithiasis: men are affected 3 times more often than women
Along with the general causes of an endogenous and exogenous nature in the formation of urinary stones, local changes in the urinary tract (developmental anomalies, additional vessels, narrowing, etc.) are also of undeniable importance, causing disruption of their function.
Kidney stones can be single or multiple (up to 5000 stones). The size of the stones varies – from 1 mm, to giant ones – more than 10 cm and weighing up to 1000 g.
CLINICAL PICTURE
The disease can be asymptomatic, manifested by pain of varying intensity in the lumbar region or renal colic.
THE MOST CHARACTERISTIC SYMPTOMS OF URINOSIS DISEASE ARE:
Pain in the lumbar region – can be constant or periodic, dull or acute. The intensity, localization and irradiation of pain depend on the location and size of the stone, the degree and severity of obstruction, as well as the individual structural characteristics of the urinary tract.
Large pelvic stones and coral kidney stones are inactive and cause dull pain, often constant, in the lumbar region. Urolithiasis is characterized by pain associated with movement, shaking, riding, and heavy physical activity.
Renal colic (RC) is an attack of acute pain in the lumbar region caused by obstruction of the upper urinary tract. As a rule, the occurrence of PC is associated with the migration of stones from the renal calyx or pelvis to the ureter. The mechanism of occurrence of PC: as a result of a violation of the outflow of urine, intrapelvic pressure increases, which leads to disruption of microcirculation in the kidney, venous stagnation and irritation of the receptors of the sensory nerves of the gate and the fibrous capsule of the kidney, resulting in a characteristic attack of pain.
The incidence of PC in the population is 1-12%, with more than half of the cases occurring in the male half of the population. It should be noted that 13% of cases of the total number of patients with renal colic occur due to other diseases of the kidneys and ureter (tumors, tuberculosis, hydronephrosis, urovasal conflict, retroperitoneal fibrosis) and are associated with the passage of blood clots, pus, and mucus that close the lumen of the urinary tract. Colic that occurs as a result of renal pathology is one of the most severe types of pain, requiring first aid, emergency diagnosis and treatment.
PC occurs suddenly after driving, shaking, drinking too much liquid, or drinking alcohol. The pain is so severe that patients rush around the room, constantly changing location and position, which usually does not bring them relief. This characteristic behavior of the patient often makes it possible to establish a diagnosis “at a distance.” The pain may radiate to the groin area, genitals (scrotum, penis, vagina and labia), and may intensify with urination.
ZONE OF IRRADIATION OF PAIN IN RENAL COLIC
Of the general symptoms, the symptoms of intoxication come to the fore: nausea, vomiting, which does not bring relief; Due to intestinal paresis, it becomes difficult to pass gases. Depending on the location of the obstruction, false urges to defecate and urinate may occur. Body temperature may rise to subfebrile levels (37.1 – 37.5 ° C), the frequency of heart contractions may decrease, and blood pressure may slightly increase. Urine may turn pink or red if the stone damages the wall of the ureter or kidney cavity. The pain sometimes continues for several hours or even days, periodically subsiding.
INDEPENDENT DISMISSAL OF STONE
Extremely rare – obstructive anuria (with a single kidney and bilateral ureteral stones). In children, none of these symptoms are typical for urolithiasis. PC in children is characterized by localized pain in the navel with vomiting. Children are usually restless and whiny.
KSD DIAGNOSIS
Manifestations of urolithiasis may resemble symptoms of other diseases of the abdominal cavity and retroperitoneal space. That is why a urologist first of all needs to exclude such manifestations of an acute abdomen as acute appendicitis, uterine and ectopic pregnancy, cholelithiasis, peptic ulcer, etc., which sometimes needs to be done together with doctors of other specialties. Based on this, determining the diagnosis of KSD can be difficult and lengthy, and includes the following procedures:
1. Examination by a urologist, obtaining a detailed medical history in order to fully understand the etiopathogenesis of the disease and correct metabolic and other disorders for the prevention of the disease and metaphylaxis of relapses. The important points of this stage are to clarify:
- type of activity
- time of onset and nature of the course of urolithiasis
- previous treatment
- family history
- food style
- history of Crohn’s disease, bowel surgery, or metabolic disorders
- medicinal history
- presence of sarcoidosis
- presence and nature of urinary infection
- presence of anomalies of the genitourinary organs and operations on the urinary tract
- history of injury and immobilization
2. Visualization of the stone:
- Ultrasound of the kidneys, upper and lower urinary tract
Stone n\3 of the right ureter
Stone in\3 ureter
- performing survey and excretory urography or spiral computed tomography
Examination urography – right kidney stone
Exretory urography – stone in\3 of the left ureter, blocked left kidney
BILATERAL NEPHROLITHIASIS
3. Clinical analysis of blood, urine, urine pH. Biochemical examination of blood and urine.
4. Urine culture for microflora and determination of its sensitivity to antibiotics.
5. If necessary, stress tests with calcium (differential diagnosis of hypercalciuria) and ammonium chloride (diagnosis of renal tubular acidosis), and parathyroid hormone testing are performed.
6. Stone analysis (if available).
7. Biochemical and radioisotope studies of kidney function.
8. Retrograde ureteropyelography, ureteropyeloscopy, pneumopyelography.
Antegrade ureteropyelography – calculus of the pyeloureteral segment on the left.
9. Study of stones by tomographic density (used to predict the effectiveness of lithotripsy and prevent possible complications).
Complications of urolithiasis
Prolonged standing of a stone without a tendency to pass on its own leads to progressive inhibition of the function of the urinary tract and the kidney itself, up to its (kidney) death
The most common complications of urolithiasis are:
- Chronic inflammatory process at the location of the stone and the kidney itself (pyelonephritis, cystitis), which, under unfavorable conditions (hypothermia, acute respiratory infections), can worsen (acute pyelonephritis, acute cystitis)
- In turn, acute pyelonephritis can be complicated by paranephritis, the formation of pustules in the kidney (apostematous pyelonephritis), carbuncle or abscess of the kidney, necrosis of the renal papillae and, ultimately, sepsis (fever), which is an indication for surgical intervention
- Pyonephrosis – is the terminal stage of purulent-destructive pyelonephritis. The pyonephrotic kidney is an organ that has undergone purulent melting, consisting of separate cavities filled with pus, urine and tissue decay products
- Chronic pyelonephritisleads to rapidly progressing chronic renal failure and, ultimately, to nephrosclerosis
- Acute renal failureis extremely rare due to obstructive anuria with a solitary kidney or bilateral ureteral stones
- Anemiadue to chronic blood loss (hematuria) and impaired hematopoietic function of the kidneys
TREATMENT.
Due to the fact that the causes of urolithiasis are not fully understood, removing a stone from the kidney and urinary tract does not mean the patient’s recovery. The general principles of treatment of urolithiasis include 2 main areas: destruction and/or elimination of stones and correction of metabolic disorders. Additional treatment methods include: improving microcirculation in the kidneys, adequate drinking regimen, sanitation of the urinary tract from existing infections and residual stones, diet therapy, physiotherapy and spa treatment.
After establishing a diagnosis, determining the size of the stone, its location, assessing the state of urinary tract patency and kidney function, as well as taking into account concomitant diseases and previous treatment, you can begin to choose the optimal treatment method to rid the patient of the existing stone.</ p>
METHODS OF CONCRETE ELIMINATION:
- conservative methods of treatment to promote stone passage for small stones
- symptomatic treatment, which is most often used for renal colic
- operative removal of a stone or removal of a kidney with a stone
- medicinal litholysis
- “local” litholysis
- instrumental removal of stones descended into the ureter
- percutaneous removal of kidney stones by extraction (litholapoxia) or contact lithotripsy
- ureterolitholapoxia, contact ureterolithotripsy
- external lithotripsy (EBLT)
All of the above methods of treating urolithiasis are not competitive in nature and do not exclude each other, and in some cases are complementary. However, it can be said that the development and implementation of extracorporeal lithotripsy (ESLT), the creation of high-quality endoscopic technology and equipment were revolutionary events in urology at the end of the twentieth century. It was thanks to these epoch-making events that the beginning of minimally invasive and low-traumatic urology was laid, which today is developing with great success in all areas of medicine and has reached its epoch associated with the creation and widespread implementation of robotics and telecommunication systems.
The emerging minimally invasive and minimally traumatic methods of treating urolithiasis have radically changed the mentality of an entire generation of urologists, the distinctive feature of which today is that regardless of the size and location of the stone, as well as its “behavior,” the patient should and can be treated for it delivered! And this is correct, since even small, asymptomatic stones located in the calyces must be eliminated, since there is always a risk of their growth and the development of chronic pyelonephritis.
Currently, the most widely used methods for the treatment of urolithiasis are extracorporeal lithotripsy (EBLT), percutaneous nephrolithotripsy (-lapaxy) (PNL), ureterorenoscopy (URS), due to which the number of open operations is reduced to a minimum, and in most clinics in Western Europe – to zero.
REMOTE LITHOTRIPSY (DLT).
Scientist L.A. Yutkin in the 60s of the 20th century developed the theory of the electrohydraulic effect, on which the technique of remote shock wave lithotripsy is based. Shock waves are generated outside the human body, which are focused on the stone with a pressure reaching 1600 bar, these shocks destroy the stones
For the first time, external shock wave lithotripsy was performed in February 1980 at the urological clinic of the University of Munich by Professor Ch. Chaussy. Over the past quarter of a century, the technique has become firmly established in everyday practice and has become the method of choice in the treatment of various forms of nephrolithiasis. Already in 1984, the first serial lithotripter NM-3 from Dornier (Germany) was used in 170 lithotripsy centers in 20 countries.
DORNIER HM-3
Later, employees of the urological clinic of the University of Munich announced the successful use of external shock wave lithotripsy using devices from this company in thousands of patients. In 1986 in Madrid, at the IV World Congress on Endourology and Extracorporeal Lithotripsy, 180 Dornier devices were reported, on which more than 120 thousand lithotrips were performed.
DORNIER HM-4
DORNIER MPL – 9000
By the mid-80s, along with Dornier lithotripters, more advanced devices of a new generation appeared, produced by other companies: Sonolit-4000 from Technomed (France), Litostar and Litostar-plus from “Siemens” (Germany), “Edap-LP-01” and “Edan-LT-02” from Edap (France), “Tripter-XI” from Direx (USA, Israel), etc. For generating shock waves in modern devices use different principles: electrohydraulic, electromagnetic, piezoelectric, etc.
The lithotripter destroys stone using focused, high-intensity acoustic pulses. Acting on the heterogeneous structure of the stone, complex stress fields cause cracks to appear and destroy the stone.
For location and focusing, an X-ray image is used, enhanced by ultrasound guidance on many lithotripter models. External shock wave lithotripsy is so minimally invasive that it is used on an outpatient basis (Lopatkin N.A. et al., 1990, Beshliev D.A., Dzeranov N.K., 1992, Trapeznikova M.F. et al., 1992.). Currently, many authors have proven the advantages of the method not only over open surgery, but also over percutaneous puncture nephrolithotripsy (Ramadan Salaheddin, 1992, Stepanov V.L. et al., 1993).
PERCUTANEOUS NEPHROLITHOLAPAXY (PCNL)
Since Goodwin et al. first performed kidney puncture in 1955, and Harris et al. used a bronchoscope to perform nephroscopy in 1975, the rapid development of new technologies has led to radical improvements in endourological treatment methods. Currently, PCNL is a minimally invasive surgical procedure for the removal of kidney stones and has become a low-traumatic alternative to open kidney surgery.
Standard percutaneous nephrolitholapaxy is performed under general anesthesia and takes from 40 minutes to 4 hours (depending on the location, size and structure of the stone). The surgeon makes a small incision, approximately 0.5 – 1.3 cm in length, in the patient’s lumbar region. Next, a needle is inserted directly into the renal pelvis. The accuracy of the manipulation is ensured by X-ray and ultrasound methods. Then the puncture tract is gradually expanded to the required size, allowing the installation of a nephroscope, through which optical visualization of the kidney cavity is carried out, and an ultrasound or laser probe is inserted through the nephroscope to crush large kidney stones. Pieces of stones are removed and after removal is completed, a nephrostomy tube is installed to drain the kidney on the first day after surgery. In some cases, a ureteral stent is installed.
Placing the patient
Manipulations are carried out through a puncture of the skin of the lumbar region (without incisions), through which a nephroscope is inserted into the kidney.
Creating access to the renal cavity system
The method allows you to remove kidney stones of medium and large sizes (coral-shaped stones occupying the entire kidney cavity) sizes.
PERCUTANEOUS NEPHROLITHOLAPAXIA
Postoperative care
After standard PCNL, the patient remains in the hospital for another 5-6 days. During this time, additional studies will be carried out to identify residual stones. If they are present, no earlier than 2-3 days after the first operation, repeat nephroscopy is performed through the installed nephrostomy drainage. Once the stones are completely removed, the nephrostomy tube is removed and the patient is discharged.
Results
The effectiveness of PCNL in removing kidney stones is more than 98%, and in removing stones from the ureter – 88%.
Ureterorenoscopy. Contact lithotripsy
Ureterorenoscopy is an endoscopic examination of the upper urinary tract, carried out by inserting an endoscope (urethrorenoscope) through the urethra, bladder and ureteral orifices into the kidney cavity. Modern rigid and flexible ureterorenoscopes are very thin (average diameter 7.5 F). In addition, to straighten the ureter, a safety string is inserted into it at the beginning of the examination, due to which the examination is carried out without additional expansion of the ureters. The safety string facilitates the passage of the ureterorenoscope and allows the installation of a ureteral stent at the end of the operation. Thanks to this research technique, injury to the urinary tract is completely eliminated.
Drawing. Passing the safety wire through the ureter past the stone.
Indications
- Stones of the lower third of the ureter
- Stones in the middle and upper third of the ureter more than 1 cm
- Stones of the renal pelvis and calyces less than 15 mm in diameter
- Calyceal diverticulum stones
Ureterorenoscopy is not only a diagnostic technique. After detecting a stone, under visual control, a lithotripter probe is brought to it through an endoscope and crushed
Drawing. Stone fragmentation using a holmium laser
Large stone fragments are then grabbed with a basket or tongs and removed.
Drawing. Removal of stone fragments from the ureter
To remove stones from the middle and lower calyces of the kidney, flexible ureteroscopes are used, which require the preliminary installation of special casings (long hollow tubes). The operation is completed with the installation of a ureteral stent (usually for 7-14 days) and a urethral catheter for 1 day. On the 2nd day after surgery, the patient is discharged home. It is possible to perform the operation on an outpatient basis
Conservative treatment
When treating urolithiasis with medication, the doctor sets the following goals:
- prevention of stone formation recurrence
- prevention of the growth of the stone itself (if it already exists)
- dissolution of stones (litholysis)
For urolithiasis, step-by-step treatment is possible: if diet therapy is ineffective, additional medications must be prescribed. One course of treatment usually lasts 1 month. Depending on the results of the examination, treatment may be resumed.
The following medications are used to treat urate stones:
- Allopurinol (Allupol, Purinol) – up to 1 month
- Blemaren – 1-3 months
TREATMENT OF CALCIUM OXALATE STONES
- Pyridoxine (vitamin B6) – up to 1 month
- Magnesium oxide or aspartate – up to 1 month
- Hypothiazide – up to 1 month
- Blemaren – up to 1 month
TREATMENT OF CALCIUM-PHOSPHATE STONES
- Antibacterial treatment – in case of infection
- Magnesium oxide or aspartate – up to 1 month
- Hypothiazide – up to 1 month
- Herbal medicines (plant extracts) – up to 1 month
- Boric acid – up to 1 month
- Methionine – up to 1 month
TREATMENT OF CYSTINE STONES
- Ascorbic acid (vitamin C) – up to 6 months
- Penicillamine – up to 6 months
- Blemaren – up to 6 months
Preventionand metaphylaxis of urolithiasis
Preventive therapy aimed at correcting metabolic disorders is prescribed according to indications based on examination data of the patient. The number of courses of treatment during the year is determined individually under medical and laboratory supervision. Without prevention for 5 years, in half of the patients who got rid of stones using one of the treatment methods, urinary stones form again. Patient education and prevention itself are best started immediately after spontaneous passage or surgical removal of the stone
LIFE STYLE:
- fitness and sports (especially for professions with low physical activity), but excessive exercise should be avoided in untrained people
- avoid drinking alcohol
- avoid emotional stress Urolithiasis is often found in obese patients. Losing weight by reducing the consumption of high-calorie foods reduces the risk of disease
INCREASING FLUIDS CONSUMPTION:
- Indicated for all patients with urolithiasis. In patients with urine density less than 1.015 g/l. stones form much less frequently. Active diuresis promotes the removal of small fragments and sand. Optimal diuresis is considered to be 1.5 liters. urine per day, but in patients with urolithiasis it should be more than 2 liters per day.
CALCIUM CONSUMPTION.
- Indications: calcium oxalate stones.
- Higher calcium intake reduces oxalate excretion.
CONSUMPTION OF FIBER
- Indications: calcium oxalate stones
- You should eat vegetables and fruits, avoiding those rich in oxalate
CONSUMPTION OF VITAMIN C.
- Consumption of vitamin C up to 4 g per day can occur without the risk of stone formation. Higher doses promote the endogenous metabolism of ascorbic acid to oxalic acid. At the same time, the excretion of oxalic acid by the kidneys increases
REDUCING PROTEIN CONSUMPTION:
- Animal protein is considered one of the important risk factors for stone formation. Excessive intake may increase calcium and oxalate excretion and decrease citrate excretion and urinary pH
- Indications: calcium oxalate stones
- It is recommended to take approximately 1g/kg. protein weight per day
THIAZIDES:
- The indication for thiazides is hypercalciuria
- Drugs: hypothiazide, trichlorothiazide, indopamide
SIDE EFFECTS:
- mask normocalcemic hyperparathyroidism
- development of diabetes and gout
- erectile dysfunction
ORTHOPHOSPHATES:
- There are two types of orthophosphates: acidic and neutral. They reduce calcium absorption and calcium excretion as well as they reduce bone reabsorption [64]. In addition, they increase the excretion of pyrophosphate and citrate, which increases the inhibitory activity of urine. Indications: hypercalciuria
COMPLICATIONS:
- diarrhea
- stomach cramps
- nausea and vomiting
Orthophosphates can be an alternative to thiazides. Used for treatment in selected cases, but cannot be recommended as a first-line treatment. They should not be prescribed for stones combined with a urinary tract infection.
ALKALINE CITRATE:
Mechanism of action:
- reduces supersaturation of calcium oxalate and calcium phosphate
- inhibits the process of crystallization, growth and aggregation of stone
- reduces supersaturation of uric acid
INDICATIONS: CALCIUM STONES, HYPOCITRATURIA
Magnesium:
- Indications: calcium oxalate stones with or without hypomagniuria
SIDE EFFECTS:
- diarrhea
- CNS disorders
- tired
- drowsiness
MAGNESIUM SALTS CANNOT BE USED WITHOUT USING CITRATE
Glycosaminoglycans:
Mechanism of action: calcium oxalate crystal growth inhibitors.
Indications: calcium oxalate stones
LITHOTRIPSY AT NEW LIFE CLINIC.
The capabilities of our clinic allow us to provide modern treatment for such a common urological pathology as urolithiasis. Good human health is not determined by the number of stones in the body. Quite the opposite. The time to collect stones must be replaced by the time to get rid of them. There are many ways. The extracorporeal shock wave lithotripsy we perform on an outpatient basis, as well as low-traumatic operations on the kidneys and ureters using a thin endoscopic instrument, allows us to crush and completely remove stones from the urinary tract, which allows the patient to return to a full life in record time after surgery, without external signs of surgery.
