The Ministry of Education and Science of Ukraine

THE MINISTRY OF EDUCATION AND SCIENCE OF UKRAINE SUMY STATE UNIVERSITY MEDICAL INSTITUTE

Methodical instructions for practical work «Kidney Stone Illness» for the discipline "Urology" (according to Bolonsky system) For 5th year-students Specialities 7.110101 full time training

Sumy SumSU 2007 The educational edition

Methodical instructions for practical work «Kidney Stone Illness» for the discipline "Urology" (according to conditions of Bolonsky system) for 5th year-students, speciality 7.110101 full time training

Editor V.V. Sikora

Contributor N.V.Lisogub V.D.Shishchuk Commissioning editor

subscription In the seal 2007, poses. Format 60х84/16. offset paper. Offset printing. Mind(Wit). A seal. арк. Region - a kind. sheet. Circulation 50 issues. The cost price a kind. The deputy № Publishing house Sumdu at the Sumy State University 40007, Sumy, street. Rimskogo-Korsakova, 2 The publishing certificate regisreration Recreation center № 2365 from 08.12.200 printed by SumSU

40007, Rimskogo-Korsakova street,number 2. Methodical instructions for practical work «Kidney Stone Illness» for the discipline "Urology" (according to Bolonsky system) For 5th year-students Specialities 7.110101 full time training

Sumy SumSU 2007 Methodical instructions for practical work «Kidney Stone Illness» from the discipline of "Urology" (according to Bolonsky system) / Тhe editor V.V. Sikora. - SumSU, 2007.- 24 p.

Faculty of orthopaedics, traumatology and NS Place of carrying out: reception, wards, operational, dressing, lecture room, lithotripsy and radiologic rooms. The purpose of work - to teach symptomatology and diagnostics of urolithic illness, its complications, and also indications for conservative and operative treatment. Typical diagnostic and tactical mistakes and ways of their prevention. Professional technique recommadations for students. Urolithic illness is enough widespread disease, which has been known since olden days. Among all urological diseases UROLITHIASIS accounts for 30 – 40%. For the last years some increase in desease among women was marked in comparison with men. Among patients with urolithic illness severe cases are especially represented by patients with coral-like stones (in the ratio 3:1). Basic level of knowledge and skills 1 Anatomic-physiological features of urinary systems. 2 Collecting the anamnesis, carrying out physical inspections. 3 Etiology and pathogenesis of UROLITHIASIS. 4 Radiological, tool, laboratory, endoscopic methods of research in diagnostics of UROLITHIASIS. 5 Application of remedies of etiological, pathogenetic and symptomatic therapy. The program of students’s self-preparation 1 Basic symptoms of UROLITHIASIS. 2 Proving and formulating the clinical diagnosis. 3 Differential diagnostics of UROLITHIASIS with kidney tumour, kidney tuberculosis, nonspecific inflammatory processes of kidneys. 4 Medical management of urolithic illness: indications and contra- indications to operative, conservative treatment of UROLITHIASIS, lithotripsy. Illustrative material 1 Slides: 1.1 Different kinds of plastic pyeloureteral segment. 1.2 Nephrotomy. 1.3 Pyelolithotomy. 1.4 Remote lithotripsy. 2 X-ray examinations: 2.1 Plain urography - bilateral ureterolithic. 2.2 Excretory urography - hydronephrosis of the second degree. 2.3 Retrograde pneumopyelography – coral-like kidney stone . 2.4 Plain cystography – concrement of urinary bladder. 2.5 Plain urography - a stone on the third level of ureter. 2.6 Plain urography - loopback extraction of concrement. Technique of performing practical work Work 1 Proving and formulating the clinical diagnosis. The student takes complaints, the anamnesis of disease and life of the patient, carries out objective inspection, finds out basic clinical attributes of UROLITHIASIS, makes the diagnostic plan and formulates the diagnosis. Questions which the student should answer. 1 What are the clinical symptoms of UROLITHIASIS? 2 What are the complications of UROLITHIASIS? 3 What are the basic methods of examination of patients with UROLITHIASIS? Work 2 Carrying out the differential diagnostics. On the basis of complaints, the anamnesis of disease and life, the data of objective inspection, laboratory and ultrasonic researches the student carries out the differential diagnosis of the patient with UROLITHIASIS. Questions which the student should answer. 1 The differential diagnosis of what diseases is carried out? 2 What therapeutic approach should be used in treating patients with UROLITHIASIS? 3 What modern directives are known to be used in treatment of patients with UROLITHIASIS? Situational problems(tasks) with standard answers 1 Patient С. of 52 years old complains of intensive pains in the right iliac region and on the right side of the waist, often with gripping intestinal pain on urination. Morbidity in the right ureter is marked. Pasternatsky’s Symptom is positive on the right. Shadows of concrement are not seen on the plain urography. What is your previous diagnosis? With what diseases is it necessary to carry out the differential diagnosis? What is necessary to carry out for specification of the diagnosis? The answer. Right-side renal colic. Appendecitis. For total examination it is necessary to carry out chromocystoscopy, ultrasonic examination, and also retrograde pneumoureterpyelography, if necessary. 2 Patient L. of 34 years old has typical clinical left renal colic. On inspection pathological changes of urine were not revealed . What examination is it necessary to carry out in order to confirm the diagnosis? Is it possible to explain the normal analysis of urine? The answer. Plain and excretory urography. In case of full ureteral obstruction normal urine will act in a bladder only from the healthy kidney.

Tests 1 Complications of nephrouretrolithiasis. A Acute pyelonephritis, chronic pyelonephritis, anuria, acute delay of urine, hydronephrosis. B Acute pyelonephritis, chronic pyelonephritis, calculous pyonephrosis, acute and chronic renal insufficiency, nephrogenic hypertensia. C Chronic pyelonephritis, acute pyelonephritis, acute delay of urine. D Chronic pyelonephritis, chronic renal insufficiency, calculous pyonephrosis, paradoxical ischuria nephrogenic hypertensia. E Acute calculous pyelonephritis, calculous pyonephrosis, hematuria, pyuria, anuria. 2 What stones are formed in the alkaline enviroment? A Oxalates. B Phosphates. C Urates. D Cystine. E Carbonates. 3 What disease is characterized by attack-like pains in the waist, dysuria, hematuria, discharge of concrements, leukocyturia? A Urolithic illness. B A tuberculosis of kidneys. C Pyonephrosis. D Kidneys tumour. E Acute prostatitis. 4 Concrement of what chemical composition is yellow with corpulent surface and firm consistence? A Phosphates. B Oxalates. C Carbonates. D Urates. E Cystine. 5 Oxalate concrements are bagically: A Black, soft, are easily crumbled. B Corpulent or rough, light grey, soft. C Yellowy-brown, corpulent, have firm consistence. D Corpulent, white, soft, different in shape. E Dense, black – grey with uneven stock. 6 Among the basic symptoms of urolithic illness is/are: A Pain in the waist. B Pain in the waist, dysuria, hematuria, discharge of concrements. C Pain in the waist, hematuria, pyuria, dysuria, independent discharge of concrements. D Hematuria, nicturia, pyuria. E Oliguria, pain in the waist, dysuria. 7 If X-ray negative concrement is seen in the kidney capsule the most informative method of its diagnosis is: A Plain urogram. B Retrograde pyelography. C Infusion urography. D Retrograde pneumopyelography. E Orthostatic excretion urography. 8 Oxalates are: A Potassium salts of hydrochloric acid. B Calcium salts of phosphoric acid. C Calcium salts oxalic acids. D Potassium salts of amminocapronic acid. E Potassium salts of citric acid. 9 For diagnostics of X-ray negative concrements of bladder … is carried out: A Plain cystography. B Retrograde pneumocystography. C Policystography D Sedimentary cystography. E Partial cystography. 10 In case of oxalaturia it is desirable to exclude … from the diet: A Meat, cheese, milk. B Fish, meat, fruit. C Potato, carrots, milk. D Liver, bacon, bread. E Cheese, eggs, sour cream, kefir, meat broth. 11. What method of operative intervention is the most appropriate to suggest when a concrement measuring 9x6 mm is found in the lower third of the ureter? A Ureterostomy. B Pyelolithostomy. C Nephrolithostomy. D Ureterolithotomy. E Loopback extraction of concrement. 12 Pyelolithotomy can be: A Front and back. B Upper and lower. C Direct and slanting. D Closed and open. E Penetrating and not penetrating. 13 In case of coral-like kidney stone … more often is/are used: A Hemodialysis and hemosorption. B Pyelolithotomy and nephrotomy. C Conservative treatment. D Ureterocystoneostomy. E Autotransplantation of kidneys. 14 As a tool for removing concrements from urter … is used: A Ureterocystoscope. B Fedorov’s Ex-tractor. C Abraham’s Basket. D Ceisa’s Loop. E Fogarti Catteter. 15 Indications for nephroctomy is/are: A Senile age of the patient. B Nephrogenetic arterial hypertension. C Nephroptosis and hydronephrosis. D Lare-size concrement E Hematuria and pyuria in case of calculous pyelonephritis. 16 Before operative treatment of the kidney it is necessary to find out: A Passableness of urethra and ureter on the affected side. B Presence of residual urine. C Accompanying cardiological diseases. D Available infectious diseases. E Presence of the second kidney and its functional ability. 17 For dissolution of concrements are used: A Avisanum, Cistenal, Enatinum, Nospanum. B Urolisin, Phytolysinum, a hydrochloric acid. C Prolit, Litivit, Phitolet, Blemaren D Spasmocystenal, Artemizol, Sophradexum. E Norbactin, Palin, cystophit, Corduru. 18 For reducing a longactive attack of renal colics … is used: A Vishnevsky’s Blockade. B Pirogov’s Blockade . C Fedorov’s Blockade . D Zeldovich’s Blockade . E Lorin-Epshtein Blockade. 19 For reducing an attack of renal colics … more often are used: A A diet, ET, a hot bath. B ET, diuretics, antibiotics. C Spasmolytics, uroantiseptics, anesthetics. D Uroantiseptics, antibiotics, bloodstopping. E Hot bathing, phytodiuretics, spasmolytics. 20 Contra-indication to lithotripsy in the bladder is: A Chronic cystitis, small capacity of the bladder, paracystitis. B Stricture of urethra, acute cystitis, paracystitis, small capacity of the bladder, fixed stone. C Stricture of urethras, pyuria, small capacity of the bladder. D Hematuria, stricture of urethra, acute and chronic cystitis. E Paracystitis, small capacity of the bladder, a chronic and Acute cystitis. 21 A patient of 36 years old had repeating left-side renal colics during last week. He was hospitalized to the urology department. Palpation on the left kidney is painful, Pasternatsky’s symptom is positive on the left. Spasmoanalgetics reduce pain insignificantly. Ultrasonic examination showed dilatation of ureter. Name optimum further tactics of treatment. A Repeated introduction of Nospanum, Baralgin, Promedol, Platiphilini etc. B Novocaine blockade by Lorin-Epshtein. C Ingestion of tamsuliosin (omnika). D Introduction of dyclofinak intramuscularly. E Emergent catheterisation of ureter or through skin puncture nephrostomy.

22 A patient of 47 years old didn’t have urination and desires to it for last two days. 8 years ago he underwent left-side nephrotomy because of damage of the kidney. Last month the blunt pain in the right lumbar side was marked. It had the character of renal colics that happened three days ago. After application of spasmoanalgetics the pain almost disappeared. What result of laboratory inspection is crucially important for the choice of treatment of the patient? A Potassium of blood. B Urea, creatinine of blood. C Sodium of blood. D Calcium of blood. E Hemoglobin of blood. 23 Last month a patient of 32 years old had attacks of right-side renal colics which were weakened after injections of spasmolytics and anaesthetics, low-grade fever increased three times. A day ago there was an attack of the pain in the right lumbar side and the body temperature raised up to 39С, the fever was observed. On palpation, pain insignificantly increased in right kidney. Pasternatsky’s symptom is positive in the right kidney. What is the most possible pathology which predetermines such clinical presentation? A Stone in the right ureter. B Acute cystitis. C Chronic pyelonephritis in a phase of aggravation. D Cystalgia. E Stone of the bladder. 24. A patient had acute pains in the right half of stomach. The pains irradiated to the waist, genitals. There is often pain on urination. The stomach is a bit blow like, moderately painful in the iliac side of the right region. Pasternatsky’s symptom is positive on the right. What is the previous diagnosis: A Acute appendicitis. B Acute cholecystitis. C Acute intestinal impassability. D Acute pancreatitis. E Right-side renal colics. 25 A patient of 34 years old was hospitalized with complains of strong cramping pain in the right side of the the stomach radiating to the groin. Most probably renal colics are caused by: A Stone of the lower third of the ureter B Stone in the pelvis of the right kidney. C Stone of the bladder. D Stone of the urethra. E Papilloma of the bladder on the right side of triangle L’eto. 26 Patient H.of 36 years old had moderate pains in the left lumbar region during 5 days. In the evening the low-grade fever suddenly raised up to 39,8o C and intolerable pain appeared in the left lumbar region. On examination the patient’s condition was heavy. He had mixed consciousness. The stomach was soft, moderately painful during palpation in the left hypogastric side. Schetkin-Blumberg symptom was negative. Pasternatsky’s symptom was acutely positive on the left, moderately positive on the right. On the series of excretorial urograms there was visualization of stone in the pelvis-ureter segment. There was the diagnosis of urolithic illness with stone in the left kidney. What therapeutic approach should a doctor choose? A Carrying out massive antibacterial therapy. B Antibacterial therapy in view of sensitivity. C Remote crushing of the stone. D Nephrotomy. E Immediate operative intervention: pyelolithotomy, nephrostomy, decapsulation. 27 A patient of 42 years old had acute pain in the waist on the left side radiating to the left half of stomach, and to the groin. The pain was accompanied with nausea, vomiting. After the warm bath and taking baralgin the pain disappeared. Clinical analysis of urine showed hematuria, on ultrasonic examination of kidneys a stone of 0,2 mm was found. What is your diagnosis: A Acute pyelonephritis. B Urolithic illness. C Acute glomerulonephritis. D Kidney tumour. E Cystitis. 28 Emergency team has come to a patient of 35 years old. The patient complains of acute pains on the right side of the waist radiating to the groin. The patient holds on the sick side, groans, finds no place. Acute weakness, dryness in the mouth, nausea is marked. On palpation there is acute morbidity in the right lumbar side. Pasternatsky’s symptom is acutely positive on the right. There is macrohematuria in urine. What is the most probable cause of macrohematuria: A Urolithic illness complicated with renal colics. B Acute glomerulonephritis . C Extrauterine pregnancy. D Tumour of the bladder. E Spontaneous abortion. 29 A patient of 48 years old was hospitalized to urology department with complaints of pain in hypogastrics, perineum, absence of urination for one day, rise in body temperature up to 38,8С, fever. Pallor skin, pulse 90 for 1 minute, the ABP of 130/90 mm, vesicular breathing is observed on examination. Tones of heart are rhythmic, clear. Stomach is blowed off; liver, spleen, kidneys are palpated. Percussion showed that borders of the bladder are 3 cm lower than navel. Pasternatsky’s symptom is positive on both sides. A week ago pains began to disturb in the right lumbar side. They radiated to ureter, perineum. Gripe on often urination was marked. Urine changed its color to red – brown. Fever was observed. For about 10 years the patient has been suffering from urolithic illness with acute attacks 1-2 times a year, chronic calculous pyelonephritis with aggravationsand discharge of concrements. What is your previous diagnosis: A Concrement obturation of urethra. B Cancer of prostatic gland. C Acute renal insufficiency. D Adenoma of prostatic gland. E Acute prostatitis. 30 Patient of 38 years old was hospitalized to urological department with complaints of pains in hypogastry, perineum, absence of urination for one day, rise in body temperature up to 38oС. Pallor skin, pulse 100 for 1 minute, BP of 140/90 mm is observed on examination. There is vesicular breathing in lungs. Tones of heart are rhythmic, clean. Stomach is blowed off, liver, spleen, kidneys are not palpated. Percussion showed that the borders of the bladder are 4 cm lower than navel. Pasternatsky’s symptom is positive on both sides. The patient had been ill for 2 weeks when pains began to disturb in the right lumbar side. They radiated along ureter, to perineum. Gripe on often urination was marked. Urine changed its color to red - brown. Fever was observed. For about 10 years the patient has been suffering from urolithic illness with acute attacks 1-2 times a year, chronic calculous pyelonephritis with aggravations and discharge of concrements. The list of tests for definition of the diagnosis and choice of treatment is: A Ultrasonic examination of kidneys, prostatic gland and bladder, manual rectal research, retrograde urethrography. B Ultrasonic examination of kidneys, prostatic gland and bladder, plain urography, retrograde urethrography. C Ultrasonic examination of kidneys, prostatic gland and bladder, manual rectal research, plain urography, retrograde urethrography, excretion urography. D Ultrasonic examination of kidneys, prostatic gland and bladder, manual rectal research, plain urography, retrograde urethrography. E Ultrasonic examination of kidneys, prostatic gland and bladder, manual rectal research, plain urography, retrograde urethrography, urea and creatinin of blood. 31 Sick M. of 52 years old was hospitalized to urology department with complains of pains in hypogastry, perineum, absence of urination for a day, rise in body temperature up to 37,8o С. Pallor of skin, pulse 96 for 1 minute, the ABP of 130/80 mm, vesicular breathing is observed on examination. Tones of heart are rhythmic, clean. Stomach is blowed off, liver, spleen, kidneys are not palpated. Pasternatsky’s symptom is positive on both sides. The patient became ill one week ago when pains began to disturb in the right lumbar side. They radiated along ureter to perineum. There were pains on often urination; urine changed its color to red. Fever was observed. For about 6 years the patient has been suffering from urolithic illness, chronic calculous pyelonephritis with discharge of concrements. What diagnostic method helps to exclude the diagnosis of bladder concrement: A Manual rectal research. B Ultrasonic examination of the bladder C Retrograde cystography D Excretion urography E Descending cystography 32 Patient of 45 years old was hospitalized to urology department with complains of pains in perineum, absence of urination for 12 hours, rise in body temperature up to 39,8 oС. Pallor skin, pulse 110 for 1 minute, the BP of 130/90 mm, vesicular breathing is observed on examination. Tones of heart are rhythmic, muffled. Stomach is blowed off, liver, kidneys are not palpated. Pasternatsky’s symptom is positive on both sides. The patient became ill 6 days ago when pains began to disturb in the left lumbar side. They radiated along ureter, to perineum. There was gripe on often urination; urine changed its color to brown. For about 15 years the patient has been suffering from urolithic illness, chronic calculous pyelonephritis with an aggravation and discharge of concrements. What medical preparations is it necessary to prescribe for the patient first of all: A Febrifugal B Diuretic. C Spasmolitics. D Antibiotics. E Analgetics. The student should know: 1 Etiology and patogenesis of UROLITHIASIS. 2 Chemical composition of stones and conditions of their formation 3 Symptomatology and course of stones in kidneys and ureter. 4 Diagnostics of ureteral stones. 5 Differential diagnostics between renal colics and acute surgical diseases of abdominal cavity. 6 Conservative treatment of UROLITHIASIS. 7 Operative treatment of UROLITHIASIS. 8 Treatment of renal colics. 9 Urolithic illness in the pregnant and children. 10 Complications of UROLITHIASIS and their treatment. 11 The causes of bladder stone formation. 12 Clinic and diagnostics of bladder stones. 13 Medical tactics concerning the patients with bladder stones.

The student should be able: 1 To find out basic clinical attributes of UROLITHIASIS. 2 To prove and formulate the clinical diagnosis. 3 To make the program of additional methods of inspection. 4 To carry out differential diagnostics. 5 To prove conservative treatment and indications to operative intervention. 6 To estimate excretory, retrograde urography with different contrast substances and oxygen.

The list of the basic literature 1. Vozianov O.F., O.V. Cradle of The Urology. - К., 1993. 2. Urology Under the editorship of N.A.Lopatkina.-î, 1982. 3. Urology / Under Under the editorship of acad. N.A.Lopatkin. - М., 2001. - 516 p.

The list of the additional literature

1. Hydronephrosis / Under the editorship of V.S.Karpenko. - Kiev: Health, 1991. 2. Dzeranov N.K., Yanenko E.K. Operative Treatment of Coral-like Nephrolithiasis // Urology, 2004. - №1. - p. 34-38. 3. Lopatkin N.A.Management of Urology. - М., 1998. - Т2, Chapter (Head) 29. 4. Osipova N.A., Novikov G.A., etc. Actual Aspects of Pharmacotherapy of the Chronic and Acute Pain // Anest. and resuscitation. - 1993. - №6. - p. 22-29. 5. Pytel J.A., Zolotaryov I.I.Uratnyj Nephrolithiasis. - M.: Medicine, 1995. - 182 p. 6. Tiktinskiy O.L., Alexanders V.P. Urolithic Illness. - СПб.: Peter, 2000. - 379 p. 7. Tiktinskiy O.L., Novikov I.F. Urolithic Illness. - Lviv.: Knowledge, 1991. 8. Uyegov G.P. Nephrolithiasis. - Rostov - on - Don: Prof-Press, 2000.-121 p.

Short methodical instructions to carry out on practical work At the beginning of work the test control of the initial level of knowledge will be carried out. Then - independent work of students with patients. Under the direction of a teacher clinical analysis of the case record will be carried out. At the end of work there will be the final test control or resolution of situational problems.

Technological card (map) of carrying out of employment Nu Stage Time, The manual Place of mb minute Means of The carrying out er. training equip ment 1 Definition of an 30 Tests Educational initial level of room knowledge 2 Treatment of 20 Patients Chambers patients under the direction of a teacher 3 Clinical analysis 30 Case Educational of patients under records, room the direction of algorithms the teacher 4 Substantiation of 20 Tables, Educational the previous circuits, room diagnosis algorithms 5 Substantiation of 20 Tables, Educational medical tactics circuits, room algorithms 6 The final control 20 Tests, Educational situational room problems (tasks) 7 Conclusion to 20 Educational results of work room Enclosure A (obligatory)

Renal stone

Insoluble stone Infected urinary Soluble stone system

kidney drainage through litholysis antibiotics the skin Stent + ESWL + litholyisis Size of the stone stone≥20 mm

stone≤ 20 mm TSPL 18

TSPL ESWL Fragmentation Residual stone Unsuccessful Absence of Fragmentation

Opened pyelo-, calico-, nephrolithotomy Repeated ESWL

Pic. 1 - Algorithm of treating the patients with kidney stone illness Enclosure B (obligatory)

Stone in the top third of u the ureter Soluble stone Insoluble stone камінь Infected urinary system Putting stent + litholysis antibiotics Absence of effect kidney drainage with stent or through skin nephrostomy Stone ≥ 1,5 cm stone ≤1,5 cm Size of the stone ESWL in situ

1 Retrograde moving of a stone to Retrograde moving of a stone

9 the kidney to the kidney Absence of Fragmentation Fragmentation

Successful Unsuccessful Successful Repeated ESWL е

TPSL Stent + ESWL Anterograde skin contact lithotropsy

endoscopic (laparoscopic) ureterolithotomy Opened ureterolithotomy

Pic. 2 – Algorithm of treating the patients with stones in the top third of the ureter Enclosure C (obligatory) Stone of an average in the third of the ureter Insoluble stone Soluble stone Infected urinary system

Percutaneous kidney antibiotics drainage or stent Stent +litholysis

0 Size of the stone is ≤ 1,5 Size of the stone is ≥ 1,5 cm Size of the stone cm

Ureteroscopy +lithotripsy ESWL in situ

Retrograde moving of a stone to a Absence of Fragmentation kidney Fragmentation Repeated ESWL Unsuccessful Successful obligatory Anterograde ureterolithotripsy Size of stone ≤ 1,5 sm endoscopic (laparoscopic) Size of the stone is ≥ 1,5 sm ureterolithotomy Absence of Fragmentation ESWL Opened ureterolithotomy Stent + ESWL TPSL

Pic. 3 – Algorithm of treating the patients with stones in middle third of the ureter Enclosure D (obligatory) Stone of the lower third of the Renalureter colic, arised for the first time

o Infected urinary system pain, increase in t , Pain on the right or on the left To take detailedSize of anamnesis the stone Fever for several side after earlier made days appendectomy

2 antibiotics Pain on the right side in case of absence of 1 appendectomy in anamnesis at the slightest doubt in diagnosisSize of the stone is ≥ 1,5 cystochromoscopySize of the stone is ≤ 1,5 cm cm Liquidation of Percutaneous kidney a painful drainageRoutine or stent examination: Depending on the size of concernment fringement syndrome General analysis of urine urodynamic( the expansion of ureter higher the localizationESWL in situ of General analysis of blood stone, pyeloectasia, hydronephrosis ) bacteriemia, attributes US obstruction (intensive pains,t, fever) plain Rg-graphyUreteroscopy of kidneys +lithotripsy Absence of Fragmentation Fragmentation and ureters (excretory It is not Attack is urography) Concrement is revealed (size, localization) liquidated liquidated Putting stent Repeated ESWL Unsuccessful Large Concrement is not revealed, there Small and average concrements (0,2-0,4 sm) concrement are no infringements of urodynamics, in calices , pelvis,ureter (more than 1 sm) endoscopic (laparoscopicnephroptosis) , kidneys abnormalityOpened, ureterolithotomy in kidney or ureterolithotomypain does not analysis of urine are normal repeat Out-patient treatment ureter

Pic. 4 -« EpisodeAlgorithm» in life of the treatment patient (Does the not patients withSudden stones increase in bottom in the bodythird t up of to ureter more than 37,5C, require the further treatment) Aggravation of a pain, macrohematuria, leucocyteuria, Deterioration of kidney functions Enclosure E (obligatory)функції нирок

stationary Treatment : ESWL, electrophysical ureterolithotripsy, Mechanical ureterolithotripsy, ureterolithoextrachion, catheterization, Section of ureter, cystolithotripsia , pyelolithotripsia

Pic5 – Algorithm of diagnostics and treatment renal colic and kidney stone illness 2