Urinary Stones Disease

URINARY STONES DISEASE

Urolithiasis is the most frequent cause of the surgical operations at the kidneys and ureters. Urolithiasis takes 30-15% of all the urologic diseases. Ethiology and pathogenesis. The disease develops of many factors. It may develop because of congenital abnormalities, vitamins & microelements deficiency, hormonal dysfunction, urine pH oscillations, inflammatory process etc. The congenital tubulopathias (enzymopathies) make basement to urinary stone development. There are dysfunction of metabolism or tubules of the kidney because of its insufficiency or any other enzyme deficiency. It makes a block of the metabolic processes. Cysturia is appearing of the cystine in urine. It is an inborn error of metabolism that is characterized by the impaired reabsorption of dibasic amino acids (cystine, lysine, ornithine and arginine) from the renal tubule and gastrointestinal tract. The alkalizing agents and a high level of fluid intake may effectively decrease the stone formation in patients with this metabolic abnormality. Lysine and arginine are well soluble, that’s why abnormality may course without clinical signs. A great frequency of urolithiasis is in people, whose parents were relatives. Glycineuria and xanthinuria are of the tubulopathies, similar to cysthinuria. Crystals of these aminoacids accumulate at the tubules of nephrone that leads to urolithiasis. These abnormalities are rare and aren’t researched completely. Oxaluria is a permanent excretion of the crystals of Calcium oxalate in urine. It is in 50% of all renal stones, and 20% of relatives of these patients have it too. Urate stones appear because of disorder of purine metabolism, when uric acid production is elevated or its reabsorbtion in tubules is decreased. The first case is followed with uric acid concentration in serum increasing (Hyperuricemia). Generalized aminoaciduria is characterized by increased elimination of the aminoacids with urine (3-6 g daily, normal rate is 1-2 g). It is observed in 60-70% of patients with urinary stones and 50% of their relatives. Patients with coral calculus and multiply bilateral stones have the elevation of the amino acids concentration in blood.

1 Galactosemia develops as a result of in complete metabolism of galactose in condition of enzyme – galactose-1-phosphat-uridile-transferase. It is followed by hypergalactosemia. It has a toxic effect on liver, kidneys, cornea, and is followed by icterus, hepatomegalia, cataract. It is an autosomal recessive inborn error of metabolism. Fructosemia is the congenital disease, caused by the deficiency of the enzyme fructose-1-phosphataldolase in the liver, kidneys, mucous membrane of intestine. Proteinuria and hyperaminoaciduria follow it. It has the recessive type of inheritation. De Tony-Debre-Fankony’s syndrome is congenital tubulopathia, error of aminoacids, glucose, phosphates, water, Sodium, Potassium, urates and proteins reabsorption. Clinical manifestation is similar to osteomalacia or rickets. Renal tubular acidosis is the common name of two syndromes. Laitve’s syndrome develops in newborns; All’Braight-Battler’s syndrome develops in elder children and grown-ups. The base of the disease is disorder of the H+ secretion, that stops Ammonium forming, titric acidness of blood decreasing. Ions of hydrocarbonate are substituted for ions of chlorine; hyperchlorine acidosis develops. The main signs of the disease are polyuria, hypercalciuria, hypernatriuria, and hypocalciemia. Nephrocalcinosis and nephrolithiasis are secondary and depend on hypercalciuria. These syndromes may be of autosomal recessive or dominant inheritation. Hyperoxaluria, urateuria, cystineuria, generalized aminoaciduria and carbohydrate errors of metabolism may be as congenital, as acquired. The acquired defects develop either diseases of the liver, kidney, acquired and congenital defects may combine. Geographically, the highest incidence of stone disease occurs in Arabic peninsula and in India. The highest frequency in Ukraine is in Donbas. The presumably dehydration dye to perspiration is common and urine contains high concentration of the lithogenic substances. But people at the North suffer from urinary stones too. The numerous researches shows the importance of hypovitaminosis especially retinol deficiency in stones formation. Iodide concentration also plays a certain role.

2 The most frequent component of urinary stones is Calcium. The elevated excretion of the parathyroid hormone because of adenoma of the parathyroid glands or their hyperplasia leads to the phosphates and calcium mobilization from the bone, which stimulates the bone destruction. It increases the intestinal absorption of calcium. Both of facts contribute hypercalciuria. Hyperparathyreoidism stimulates nephrocalcinosis and stones formation. Salts of calcium cumulate in renal parenchyma leading to its gradual necrosis. The process is bilateral and leads to renal insufficiency. There is a primary hyperparathyreoidism (parathyroid adenoma) and secondary (compensative) hyperparathyreoidism developing because of infection inflammation at the kidneys. Hypocalciemia is typical then. It is usually common while continuous traumatic immobilization that stimulates hollowing of the calcium and phosphates out of the bones. The urinary stones disease and its relapsing depends much on chronic pyelonephritis. It predicates stones formation in 30-35% of cases. Stone formation on base of pyelonephritis is initiated by two ways: 1) stone matrix formation and salt deposition, which are out of the urinary sediment. The organic matrix consists of the bacteria bodies, leukocytes, and some post-inflammative urinary tract substances. Urinary sediment appears because of pH alkalization as a result of urinary congestion and infection. The low pH rate (5,0 and lower) favors uric acid and its salt sedimentation. The high pH rate (7,0 and higher) favors phosphates sedimentation. The normal pH rate may be followed with oxalate stones formation. The amorphic salts or crystals may get out during the renal colic. A high concentration of salts in urine may be the result of colloid-crystalloid disbalance. The protective colloids (magnesium, pyrophosphate, citrate, phosphocitrate, diphsphonate, mucoproteins, various peptides and some urinary substances) inhibit crystal formation. Absence, low concentration of inhibitors or appearing in urine of glucoseaminoglycanes and polysaccharides because of chronic pyelonephritis permits crystallization.

3 Every person elder than 10 years old has calcium salts deposition at microconcentration rate at the interstitial tissue of kidneys. These salts are eliminated by means of effective lymphatic draining. Depending on the etiology the stones of organism formed because of general disorders and the stones of organ formed because of local disorders are differed. The following reasons favors the urinary stones formation (according A.Pitel and I. Pogorelko). A). Disorders of urinary tract: 1) congenital abnormalities those favor to urostasis; 2) obturative processes; 3) neurogenic dyskinesia of the urinary tract; 4) inflammative and parasitogenic damages; 5) foreign bodies of urinary tract; 6) traumatic injuries. B) Liver and digestive tract disorders: 1) latent and manifested hepathopathiy; 2) hepatogenic gastritis; 3) colitis, etc. C) Endocrine diseases 1) hyperparathyreoidism; 2) hyperthyroidism; 3) hypopituitaric diseases; D.) Infect focuses of the urogenital system. E) Metabolism disorders. 1) essential hypercalciuria; 2) disorders of membranes for colloid substances diffusion; 3) renal rickets, etc F) Injuries those leads to continuous immobilization 1) fractures of the vertebral column and limbs 2) osteomyelitis

4 3) diseases of the bones and joints 4) chronic diseases of the visceral organs and nervous system. G) Climate and geographical causes. 1) dry and hot climate with a high vaporization 2) decrease water supply 3) iodine deficiency H) Disorders of nutrition and vitamins balance: 1) retinole and oscorbine acid deficiency in food. 2) Excessive amount of the ergocalciferole in organism. Chemical composition of the stones. The most common stones are composed of the calcium oxalate. Their crystals are spine-shaped black or brown-dark colored, stones may also contain a some quantity of uric acid and its salts. Phosphates contain calcium salt of phosphoric acid. Phosphate-magnesium stones and carbonates contain calcium salts of carbonic acid. These stones are round shaped, soft, fragile, gray. These stones form in alkaline medium. Carbonic stones are homogenous, white coloured, fragile. Urates are stones of the uric acid. They are firm, smooth, yellow-brick coloured. Cystine stones are more rare and consist of the sulfuric combination of cystine. These stones are yellow, soft, round-shaped and have a smooth surface. Cholesterol stones are black, fragile, soft concrements. Protein stones consist commonly of fibrin with admixture of salts and bacteria’s bodies. They are white-coloured, soft, plain stones. These stones are X-ray negative and diagnosed as urates before the operation. There are five ways of oxalates and urates crystallization and eight ways for phosphates described. Size, shape and location of the stone are important for clinical signs. Stones shape depends on a level of its situating at the urinary tract, peculiarities of its growth. Stones are round and oval shape when located in calyces or pelvis of the kidney and the are oblong or round at the ureter.

5 The stones that are situated in one of calyces may gradually increase through all the caliceal system. They reproduce the shape of the calico-pelvic system as a cast and are called the coral calculus. There are three stages of the coral calculus growth. The stone completely fills the renal pelvis with outgrowth into calyces is 1st stage. The second stage is filling of all the large calyces. The stone completely fills the renal pelvis and all the large calyces with branches into the small calyces are the 3rd stage. Pathomorphology. Changes of the kidneys because of urinary stones disease depend on its complications (chronic pyelonephritis, hydronephrotic degeneration). The stage of the pathologic changes in the kidney and ureter also depends on the continuos, presence of the stone and infection. The continuous presence of the stone in the urinary tract leads to pyelonephritis, pyeloectasia, hydronephrosis, ureterohydronephrosis to scarring of the kidney, adipose degeneration of the kidney, pedunculitis, apostematous pyelonephritis, carbuncle of the kidney, pyonephrosis, paranephritis, damage of the mucous cover of the ureter with its following stricture, ureteritis, periurethritis, perforation of the kidney with following nephrointestinal and nephrocolic fistula formation. The short-term presence of the stone at the renal pelvis or ureter is followed with nonsignificant damages of their mucous cover. The continuous presence of the stone even in aseptic conditions leads to sclerosis and atrophy of the renal pelvis. The process spreads out there into interstitial tissue of the kidney. As a result the functional elements of the renal parenchyma perish on gradually with simultaneous adipose degeneration. The large immobile stones lead to the elevating of the intrapelvic pressure and as a result intrarenal pressure increasing. The pelvicorenal refluxes develop that favor to urine diffusion into interstitial tissue of the kidney. Scarring and sclerotic degeneration develops. The perinephral tissue involves gradually. Peripyelitis, perinephritis, pedunculitis develop. The infection accelerates the process of parenchyma destruction. The continuous presence of the stone in such condition favors the gradual involving of the medullar and cortical layers into inflammatory process

6 with formation of the infiltrates, aposthemas, and abscesses. The fibrous capsule of the kidney thickens and adheres with perinephral fat tissue. It favors induration and purulent pyelonephritis development. The calculous pyelonephritis may cause the purulent fusion of kidney (pyonephrosis). The continuous incarcerating of the hernia in aseptic conditions may lead to thickening of its wall but the inflammation develops then commonly. The perishment of the muscular elements of the urethral wall leads to urodynamic disorder. Dilatation of the ureter and renal pelvis develops gradually. Calyces dilate and hydronephrosis develops. The bladder stones lead to calculus cystitis, ureteral calculus lead to acute urinary obstruction, prostatic stones lead to chronic prostatitis. The bilateral damage causes the renal failure of certain stage, obstruction of the both ureters leads to anuria. The long- term obturation of the ureter causes the damage of the kidney damage to the opposite kidney even sometimes the other organs damage: liver, stomach, intestine etc. Great changes of coagulative and anticoagulative system, lipid and protein metabolism, peroxidation of the lipids, immune reaction appears in patients those suffer on calculous pyelonephritis. The coral calculus likes to relapse after the operation frequently. Clinical findings. The main symptoms are the following pain in loin, hematuria, and passage of salts and stones. The intensity and irradiation of pain depend on its location. A dull pain is typical for hardly mobile stones. It is intensified while movements and great introduction of fluid and manifests as renal colic. It may be caused by sudden obstruction of the upper urinary tract and continues for different term. It is accompanied by general weakness, dryness in mouth, headache, fever, dysuria, and excitement. The lower stone passes the dysuria intensifies. Micro and gross hematuria appears due to injury, pyelonephritis, venostasis of the mucosa of the calyces, renal pelvis, ureter. It stops after the complete obstruction. Ache precedes hematuria. In other diseases hematuria is followed by ache. Massive hematuria may appear due to

7 large stone that don’t completely obstruct urinary tract after long driving. This bleeding stops soon, but may relapse. Urinary stones may manifest typically. This occurs when the stone fills the whole calyx and can’t pass into the renal pelvis. This occurs while presence of the massive stones in the renal pelvis, too. There is the dyspepsia because of reflective mechanisms. Stone may be found accidentally then during research (urinalysis, plain X-ray film of abdomen. Dyspepsia is over after stone removal usually. There may be no ache when there is large stone in the ureter but without obstruction. Urine seeps by the stone and wall of ureter. There is an activation of the process when infection joins up. Fever, leykocytosis, leykocyturia, bacteriuria and local pain appear. Complication of the urinary stone disease is the hydronephrotic degeneration of the kidney. It may not be manifested for a long period. In case of complete destruction of both kidneys because of pyelonephritis and hydronephrosis anuria develops as a terminal phase of the disease. Anuria is a result of chronic renal insufficiency. Anuria appears owing to obstruction of the ureter of the single kidney (that left after the removal of another kidney or congenital the only kidney) commonly. The reflective anuria appears when the second kidney dysfunction is present on account of circulative and spastic changes at the opposite side with renal colic. Anuria is observed when both kidneys are obstructed with stones. Urine outflow stops on the background of pain. Some patients may have a light pain. The bladder is empty. The urinary pseudotenesmuses are observed when the stone stands at the terminal part of the ureter. Enlarged painful kidney may be found while palpating. X-ray finding, radionuclide renography evident the obstruction. In order to make the diagnosis following data are necessary: previous episodes of renal colic with anuria (some attacks) and clinical picture. The catheterization of ureter may persuade finally the availability of the obstacle (obstruction). Acute situations should be contradistinctioned to thrombosis of the renal vessels. But urinary tract would be permeable. Retrograde pyelography shows normal pelvis of the kidney and calyces in this case.

8 Diagnosis. Anamnesis, physical examination, laboratory, radiographic, radionuclide findings are important. Complications, and renal function should be determined exactly. A pathognomonic sign is spontaneous bursting out the stone or its surgical removal previously. On palpation enlarged kidney is painful. Pasternatsky’s symptom is positive. The enlarging of the kidney appears in consequence of hydronephrotic degeneration of the kidney. Sclerosis of the paranephral tissue may seems to be the enlarged kidney. Ache at the ureteral points is finding out. The bimanual vaginal examination determines intra- or paravesical location of the stone. The rectal examination in male doesn’t reach the terminal portion of the ureter. Chromocystoscopia shows swallowing of the ureter orifice in lower location of the stone, it may also partially project out to the orifice. Blood and urine analysis are necessary. The blood analysis lets conclude the stage of the renal decompensation and pyelonephritis activity. Micro and gross hematuria, leukocyturia, proteinuria, casts, bacteriuria may be present depending on activity of the process. A lot of renal stones are radiopaque and therefore readily visible on a plain film of the abdomen. The stones that are composed of uric acid or cystine are considered to be radiolucent and would not appear on a plain film of the abdomen. Other calcifications that may appear on a plain film of the abdomen and be confused with an urinary calculus, include calcified mesenteric lymph nodes (pills), pelvic phlebolites. Oblique film may show whether the calcification is in line with the normal anatomic position of the kidney or ureter. These findings should be named stone-like opaque bodies. Intravenous urography makes the conclusive diagnosis. It shows anatomic and functional affects. An opaque of a concrement correlates pelvis of a kidney filled with contrast medium. One should determine the stage of renal pelvis, calyces, ureter dilatation to count renal-pelvic index. Affects of calyces are equal to pyelonephritis. When there is kidneys dysfunction patient should undergo the intravenous urography with delayed films. The contrast medium fills the collecting system and ureter right to the place of obstruction with concrement frequently.

9 The retrograde urography is needed to diagnose a stone when there is an absolute obstruction of the pelvico-renal segment. Catheter should be injected not deeper than 10cm. A contrast medium should be infused slowly not more than 4-6 ml. Whether this quantity of contrast medium isn’t enough, film ought to be repeated. A catheter should stay at the ureter until the film would be displayed. Radiolucent stones are finding out as defect of contrast filling. If the film doesn’t distinctly show the pathology retrograde pneumo- and pyelography are used. A stone is distinctly visible at the gas background. Tomograhpy. Plain films tomograms may help to identify a stone otherwise obscured overlying gas and feces. Ultrasonsgraphy of the kidneys may aid in the diagnosis of the renal stones by means of acoustic shadowing. No special preparing is needed. It is not uncommon to see the perirenal or periureteral vasation of contrast medium. Angiography is instituted because of suspicions on congenital renal abnormalities. Radionuclide scanning is widely used to determine morphologic and functional affects of the “dumb” kidney. Scanning and scintigraphia determines the morphologic and functional damages of the kidney owed to urinary stones disease. Differential diagnosis. 20-25% of urolithiasis cases are atypical and stimulate various disease especially acute abdominal failures. Abdominal distention resulting from reflex of ileum or intestinal stasis may also be present and can confuse the diagnosis. It is difficult especially to distinguish the retrocaecal appendicitis and renal colic that appears due to passing stone through the right ureter. An acute appendicitis develops gradually. Renal colic starts suddenly. Mistakes are frequent when renal colic is atypical. 1/3 of patients with renal colic hasn’t radiation of ache in genitalia, perineum and hip. 2/3 of patients may no have disuria. Besides, patients with appendicitis may have disuria in consequence of pelvic or retrocaecal location of appendix. Certain significance has anamnesis (any previous attacks of renal colic or pyelonephritis).

10 Acute abdominal distension causes weakness, a low mobility of the patient, enforced posture. Renal colic patients are tossed through the bed. Heater takes off the signs of renal colic often. Difficulties of diagnosis require intravenous urography and thermography. One should remember there may be cases of both renal colic because of urinary stone disease and acute appendicitis. Chromocystoscopia and intravenous urography are required to differ these diseases. The acute cholecystitis is similar to renal colic at the right side but an icterus is present frequently and patient doesn’t toss about then. Acute pancreatitis is followed by circular pain. A high diastase rate in blood and urine is present. Perforation of the gastric and intestinal ulcer is characterized by a piercing pain at the epigastrium. There is a slim strip of air under the diaphragm at the plain X-ray film of the abdomen. The renal colic occurs because of nephroptosis when kidney descends, forming the ureter or its vessel obstruction. X-ray finding or intravenous urography confirm or exclude the diagnosis. A lot of patients with urinary stones are considered to have radiculitis. Radiation of ache is significant. Urinary stone causes pain radiating into epigastrium and lower along the ureter projection, renal colic radiates into the anterior and posterior surfaces of the hip. Radiculitis radiates along the ischiac nerve (the posterior surface of the leg). Phlebolites should be differed from urinary (bladder) stones by means of the oblique film. Treatment. Treatment may be conservative, instrumental and surgical. Conservative therapy is used in patients with uric acid diathesis and with small-sized stones those may pass out spontaneously. Renal colic is observed in patients with uric acid diathesis than with urinary stones disease. The goal is to eradicate pain. Warm bath (37C) and spasmolytic “cocktails” (with papaverine, spasmalgone, no-spanum, promedole) should be taken. Morphine hydrochloride and pantopone are not recommended because these remedies provocates

11 spasm of the ureteral wall besides good analgesic effect. Occlusion of the ureter and harmful effect on kidney still would have been present. Great efficiency has baralgine, halidor, palerol in intramuscular injections. Slow intravenous infusion of these remedies gives a quick effect. Atropine sulfates gives feeling of dryness in mouth for a long time. A high dosage of the cystenal (20 drops on the piece of sugar) is rather effective at the start of the renal colic. If ache doesn’t disappear the novocaine blockade of the spermatic cord in males and round ligament in females is required. 60-70ml of 0,25% novocaine solution heated to human body temperature is enough commonly. This procedure lets also to differ the right side renal colic of acute appendicitis. Ache doesn’t disappear in acute appendicitis. When these methods haven’t efficiency the catheterization of the ureter is instituted. If catheter passes beside concrement and urine starts to flow out (urostasis stops) ache stops, too. Catheter should be left in ureter for some hours. Obturative anuria is rather dangerous. Obturation of the ureter leads to sharp discirculation at the kidney and activation of the infectious inflammation. That’s why catheter should be guided immediately, desirable up to the renal pelvis. If the manipulation is effective the urine rapidly flows through the catheter. It may be left in the ureter for 1-2 days. Urinary outflow continues even after the catheter removal because shift of the stone happens often. Other patients have anuria again. Catheterization may be tried once again but it shouldn’t be for a prolonged time because catheter is a foreign body and favours to infection. At that case immediate surgical operation is required. While remission (inter attack period) hydratation, dissolutive stones remedies, urease inhibitors have to be prescribed. Measures may include the low-oxalate diet and a high level fluid take. Sorrel, salad, chocolate, cacao and milk products except curds and butter must be excluded. Purines should be limited in diet and alkalization of the urine should be provided. Meat and fish brothes, liver, brains, kidneys, smoked meat, cans are forbidden. A lot of fruits and vegetables, brown bread is recommended. The phosphaturia needs less receiving of the calcium and decreasing of urine pH by means of obtaining of fats, meat products, white bread. The vegetables reception must be increased.

12 An increase in fluid intake to maintain urine output 3-4l per day is required when there is no contradictions to these measures. Patient should drink fluids in breaks of food taking rhythmically during a day. A good diuretic effect has infusion (tincture) of maize corneas, small branches of cherry tree, small branches of sweet-cherry-tree, radices of parsley, of ergot. Slightly mineralized waters are recommended, too (Essentuky–20, Naphtusya, Sayrme). When uraturia Essentuky-4, -17, Smirnovska, Slavyanovska, Borgomi are recommended. When phosphaturia acidulation of the urine is required (the following mineral waters are recommended: Dolomytny Narzan, Arzny, Naphtusya). Even distillated water may be instituted. The dissolution of the calculus may be reached while uric acid diathesis and small concrements. Magurlit is a remedy containing lithium and magnesium salts those are soluble in urine. Magurlit makes the alkalization of the urine and is very effective in case of uraturia. Alkalization of urine is needed and when oxaluria because these both kinds of stones contain uric acid. Dissolution of the uric acid leads to disagregation of the stone. Cystenale, Artemizole (3-5 drops on the piece of sugar 3 times per day after meal) and Urolesan are instituted. Method of lithotripsy and stones’ removal is effective in certain conditions. The stones of the lower 1/3 of the ureter are extracted by means of different loops. The universal extractor ( Pashkovsky’s loop) let to guide it by the stone and tightly grasp the concrement. The stone is extracted right after grasping by loop. But an extractor with a small weight suspended to it external edge may be left for 24 hours in some patients. By means of special loop the stone may be broken on pieces within the ureter when the stone is to large to pass spontaneously. Extracorporal shock-wave lithotripsy permits removal of renal stones without direct surgical intervention. Ultrasonic and electrohydraulic waves and shock fragmentation of the stone is visually controlled by means of electro-optic transformator. Instruments are used with varying success for the removal and fragmentation of the ureteral stones includes

13 Durmashkins’ dilator, Ceisses’ catheter loop, Dormia’ basket. Only small stones are recommended to approach. When a large stone can’t pass away spontaneously and there are signs of ureteral obstruction with acute pyelonephritis surgical operation is needed. There are scientific researches of the question of the stones dissolution within the pelvis of the kidney. Alkalization of the urine up to 8,0 pH is provided because of cystine stones and to 6,7 because of uric acid stones. The higher pH level may lead to calcium phosphates sedimentation those may form a cover on the surface of the urate stones. On the plain X-ray film of abdomen such stone is visible as tight opaque circle with radiolucent nucleus. That’s why urine pH ought to be controlled. Patient may do it by himself by means of lakmus strip. In specialized clinics manipulation is performed in such a way. 2 ureteral catheters are guided within the pelvis of the kidney. The solution comes into the renal pelvis through the first catheter and flows out by the second. The solution contains helates those change calcium ions into other ions and favor stone dissolution. There are many reasons for surgical intervention. There are the delayed diagnosis, complication of the calculous pyelonephritis, or hydronephrosis, renal insufficiency, great size of the stone. Because of a high ability of the antobacterial remedies kidney is usually saved. Indications to surgical operation are next: 1) Frequent attacks of the renal colic or persistent pain that disables the patient. 2) Disorder of the urine outflow causing the hydronephrotic degeneration of the kidney. 3) Obturative anuria. 4) Frequent attacks of the acute pyelonephritis, progress of the chronic pyelonephritis that causes renal insufficiency. 5) Total hematuria. 6) Calculous pyonephrosis, apostematous pyelonephritis or carbuncle of the kidney.

14 7) Stone at the sole kidney that causes obstruction. 8) Stone in the ureter of the sole kidney that won’t pass away spontaneously. 9) There is a relative indication to operation. The individual method of approach should be taken. Previously the presence and function of another kidney should be determined. Operation has to remove a concrement and to create conditions to free urinary outflow, to eradicate the strictures, compressions , obstacles of the urine passage. Nephrectomy is carrying out on strict indications and with good function of the another kidney. Indications to nephrectomy are: calculous pyonephrosis, hydronephrosis at the terminal phase, apostematous pyelonephritis. The organ preserving operation is more frequent. There are the extraction of the stone and resection of the kidney. The preoperative preparing of the patient includes active measures to treat pyelonephritis, desintoxicative therapy in renal insufficiency. There are two accesses nuding of kidneys: retroperitoneal and transperitoneal. The retroperitoneal access is performed to extract concrements. The main methods are Fedorovs’, Bergman-Israels’, posterior lateral, posterior medial, intramuscular, posterior oblique-transversal with crossing on the broadest muscle of the back and anterior intramuscular access according Pogorelko. The stones are extracted through the incision of the wall of the renal pelvis (pyelolithotomy) or calyces (calicolithtomy), or parenchyma of the kidney (nephrolithotomy), or wall of the ureter (ureterolithotomy). Sometimes the nephrolithtomy is combined with pyelolithotomy (pyelonephrolithotomy). The removal of branched calculus located within the lower pole of the infundibulum or calyces (coral calculus) may be fascilated by extending or routine pyelotomy incision through the renal parenchyma overlying the lower pole of the infundibulum posteriorly. This access is called the subcortical access. Radial nephrotomy is used as a primary procedure for the removal of a solitary caliceal stone or a caliceal stone associated with a larger intrapelvic stone. In order to decrease intraoperative blood loss the radial parenchymal incisions should be made on

15 the convex border of the posterior surface whenever possible. The old pyelonephritic scales are the thinnest places thereby minimizing damage. When parenchyma is rather thin, “sectional” incision of the kidney is reasonable. To prevent relapsing the local reasons of relapses should be eradicated. Pyelolithotomy is used often. Depending the wall incised the anterior, posterior, superior and inferior methods of pyelolithotomy are differed. The most common is posterior pyelolithotomy because there are magistral vessels going across the anterior surface of the renal pelvis. Operation is performed “in situ”. The kidney isn’t mobilized from the surrounding tissues and dislocated into the operative wound. The posterior pyelolithotomy. The posterior surface of the kidney an posterior wall of the renal pelvis is nuding out the perinephral fat tissue using lumbotomy. Then revision of the pelvicoureteral segment is provided. Pedunculitis is the indication to removal of the degenerated fat capsule. Then the posterior wall of the renal pelvis is incised. Length and direction of the incision depend on size of the stone and renal pelvis. The transversal (from the Margo of the kidney to the ureter) or longitudinal incision is made. The most authors prefer the transversal incision. The concrement is extracted by means of special forceps or another instrument very carefully not to damage the pelvico-ureteral segment (while longitudinal incision). Sometimes the stone is rough and tightly clasped with the mucous cover. Such a stone has to be exfoliated from the mucous cover of the renal pelvis before the removal. The revision of the renal pelvis, calyces, pelvico-ureteral segment and ureter permeability is provided after the concrement removal. Just after this interrupted catgut suture is applied. Draining tube is guided to the incision and sutured on layers. The anterior pyelolithotomy. The anterior surface of the renal pelvis has magistral vessels and technique of such operation is complicated. After lumbotomy the anterior surface of the kidney is carefully separated near by the hilus from the fat tissue capsule by means of tupfer. If the renal pelvis is lower then vessels they have to be separated and moved above

16 opening a broad access to the wall of the renal pelvis. When the vessels are passing directly on the wall of the renal pelvis they should be parted aside. The incision is made between the vessels. The superior pyelolithotomy. This operation is required to remove stones from the superior calyx while intrarenal site of the pelvis. After lumbotomy the kidney is separated from the fat tissue capsule and dislocated by the superior pole into the operative wound. If the cruse of the kidney is short the kidney should be turned exterior and anterior by its conveyed surface. The inferior pole of the kidney is incised and the stone extracted. Subcortical pyelolithotomy. This operation is used when intrarenal situating of the pelvis. The separated wall of the renal pelvis is incised longitudinally and stone is extracted. After suturing with interrupted catgut suture the fragment of “beaded” muscle is put within the tunnel between renal pelvis and parenchyma. Calicolithotomy. Parenchyma is carefully separated from the external wall of the renal pelvis (up to the cervix of the calyces). The exfoliated posterior lip of the parenchyma is moved by means of small hooks. Then calyx is incised and stone extracted. After the pyelolythotomy, the inferior calyx is dilated significantly. That favors the urine congestion and infection. Pyelocalicoanastomosis is expedient then. If this anastomosis is impossible to do , resection of the kidney is indicated. It is also reasonable in case of hydrocalicosis in consequence of large stone. Resection of the kidney: Lymbothomy is performed. The kidney is separated out by the fat tissue capsule. Clamping of the renal artery is necessary. The transversal resection of the renal parenchyma with calyx filled with stones is used. Bleeding vessels are sutured with X- or U-shaped suture. The renal pelvis defect is sutured by interrupted catgut and continuous sutures. The muscle or fat tissue are put on a resected surface and then fibrous capsule is sutured. If coral calyces are located deeply in infrarenal pelvis they may be removed by means of nephrolithotomia.

17 To incise the fibrous capsule and renal parenchyma some incisions are proposed: sectoral, that is passing along the conveyed margo of the kidney, longitudinal incision, that is passing 0,5-1,0 cm posteriorly the conveyed margo of the kidney, and the transversal (radial) incision. Bleeding is stopped by means of Z-shaped sutures of vessels. The edges of the wound are pulled together and sutured with interrupted catgut stitches in distance 1,5- 2,0 cm from each other. The renal wound is also tamponing with a muscular fragment. Infection of the kidney, multiply or coral calyces, pyelotomy and nephrolithotomy should be supported by draining of the kidney with antiseptics, chymotripsine, chelates and continuous antibacterial therapy. Ureterolithotomy. There are retroperitoneal, transperitoneal and combined surgical accesses. It depends on stone location. To remove stone from the superior ureter the Fedorov’s access is used, from medial ureter – Cuckulidze’s or Derev’yanko access is performed, the inferior ureter – Pyrogov’s access is needed, the pelvic portion of ureter may be accessed through the suprapubic arcuate incision. The ureter should be nuded at the place of stone location. Superiorly two provisory sutures have to be applied: ureter is incised between these sutures longitudinally, then sutured by interrupted suture, not touching the mucosa. Permeability of ureter should be controlled by catheter injection. Then draining of the wound is needed. If there is two-steps operation, the interval shouldn’t be longer than 2-3 months. In case of late hospitalization the operation is carried out by two followed intervals: 1) fistula of the renal pelvis formation; 2) stone removal. Percutaneous ultrasound stone removal. A nephroscope is inserted through a nephrostomy tract to remove stone that is previously fragmented with ultrasonic control. The occasional needs for nephrostomy drainage is from some days for up to several weeks. The advantaged method is extracorporal shock-wave litothripsy. The method is based on focused hydrostroke. The recovery time is rather shortened then, inflammatory process is treated with a higher efficiency. The focused wave has enough

18 force to fragment and destroy any concrement. X-ray control let to find a concrement and to direct the focused shock-wave. There is an increasing of repetition of the operations. The reasons are the apostematous pyelonephritis, massive bleeding, urinary flow out, infection of the kidney, late reasons are nephrolithiasis relapsing, pyonephrosis, urinary fistula. Preventive measures: a) metabolic correction; b) antibacterial measures, treatment of infection; c) correction of coagulative and anticoagulative system disorders; d) support of necessary density of the urine; e) health-resort therapy; Conservative treatment is a supportive measure. The method of choice is surgical intervention. Bladder stones. Bladder stones occur in aged patients, or children. Primary stones are formed in bladder, secondary ones are passied down from the renal pelvis. Bladder stones have organic matrix, too. These stones form around foreign bodies: fragments of bones, bacteria. Disorder of urine passage favor its formation. These factors are: phymosis, stricture of the urethra, valve of urethra, diverticle, foreign bodies of urethra, atonia, tumors, prostate adenoma. Ligature stones occur. Salts may deposit at the interrupted suture, forming the concrement. Stones occur single and multiply. They may be composed of the Calcium oxalate, uric acid, urate, phosphate salts. Patients with bladder stones complain on ache, that increases during physical efforts, vesicle tenesmus. The ache appears owing to irritation of vesicle wall, intensifies while strangulation of the stone in the bladder cervix. Vesicle tenesmus appears then. Urination may restore after posture changing (laying, sitting). Then total haematuria appears. Subjective discomfort is absent at night, while sleeping. Cystitis is a frequent complication. Disuria and pollakyuria, continuous leukocyturia, bacteriuria, micro- or gross haematuria are found.

19 Cystitis may cause pyelonephritis development. Diagnosis. It isn’t complicated. Cystoscopy is the most accurate method of diagnostics. Concrements, inflammation of the mucosa because of cystitis, diverticle orifice may be visible. Most vesicle stones are radiopaque and apparent on a plain film of the pelvis. The stone within the diverticle gives a strange figure – by side of bladder borders. For accurate diagnosis ultrasonography, cystography, pneumocystography may be used. Cystoscopy may favor pyelonephritis activation. The differential diagnosis. Cystitis, benign prostate hyperplasia, stricture of urethra should be differed from the bladder stone. The main signs for stones are interrupted urine stream, its reflux, hematuria, disuria intensifying while physical work. Treatment. The method of choice is lithotripsy. Cystoscope-lithotriptor crushes the larger stones and removes the fragments under the visible control. Fragmentation may be provided by means of ultrasound and electrohydravlic stroke. Impulse generator “stroke” type gives discharge, crushing the stones. It’s not recommended at cystitis, prostatitis, ureteritis, urethritis, and in children. Surgical operation is necessary because of urethral obstruction, benign prostate hyperplasia. Operative incision is from the umbilicus to pubis (10-12 cm) along median skin line, fat tissue, aponeurosis are incised, muscles are separated in obtuse way. The peritoneal duplicature is moved up. Through the incision of the bladder wall between two forceps the stone is extracted. Bladder is sutured by interrupted suture without mucosa taking. The abdominal wall is also sutured hermetically. 2-tubes catheter is inserted into the bladder, left there for 7-10 days. Antiseptic solutions have to be administered through the catheter into the bladder. While good recovery tube is taken away on the 6th-12th day. The stones of diverticle are removed together with the diverticle. If there isn’t an urinary obstruction, a prognosis will be rather good.

20 References: 1. Donald R. Smith, M.D. General Urology, 11-th edition, 1984. 2. O.F.Vozianov, O.V.Lyulko. Urinology.- Kyiv: Vischa shkola, 1993. 3. Urinology edited by N.A.Lopatkin, Moscow, 1982. 4. Scientific Foundations of Urology. Third Edition 1990. Edited by Geoffrey D. Chisholm and William R. Fair, MD. Heinemann Medical Books, Oxford. 5. Urinary Tract Infection and Inflamation / Jackson E. Fowler, JR. MD. Year Book Medical Publishers, Chicago 1989. 6. Anderson EE. The management of ureteral calculi. Urol Clin North Am 1974;1(2):357 7. Breslaw NA, Pak CYC. Practical outpatient evaluation for recurrent nephrolithiasis. Urcl Clin North Am 1981;8(2):253-263 8. Goodwin WE, Casey VVC, Wolf W. Percutaneous trocar (needle) nephrostomy in hydronephrosis. JAMA 1955;157:891 9. Griffith DP, Klein SA. Infection-induced urinary stones. In Roth RA, Finlayson B (eds). Stones: Clinical Management of Urolithiasis. International Perspectives in Urology, Vol 6. Baltimore, Williams & Wilkins Co, 1983 10. Sheldon LA, Smith AD. Chemolysis of calculi. Urol Clin North Am 1982;9(l):121- 130 11. Smith LH. Medical evaluation of urolithiasis. Etiologic aspects and diagnostic evaluation. Urol Clin North Am 1974;12 :241 12. Ahlawat R., Whitfield H. N. Ureteric calculi: Present status and controversies // Europ. Urol. Update Series.- 1996.-V.5.- P.111-117. 13. Cohen T. D., Premigner G. M. Intracorporeal Shock Wave Lithotripsy: Electrohydraulic Lithotripsy //New Developments in the Management of Urolithiasis.- New York-Tokyo, 1996.- P. 99-107. 14. Management of Ureteric Stones /Marberger M., Hofbauer J., Turk Ch. Et al. // Europ. Urol..- 1994.- V.25.- P. 265-272.