Transcript 尿 石 症 陈
尿 石 症 Urolithiasis 陈 斌 仁济医院 泌尿外科 概 述 有史以来折磨人类最久的疾病之一 最常见的泌尿科疾病之一，男女比约3： 1 人们对于该病治疗方法的进展远超越对 于病因的了解 90%尿路结石不再采用传统的开放手术 发病有地区性，江南多于江北 概 况 形成机制未完全阐明，有多种学说 多数结石无十分理想的预防方法 近年来，肾、输尿管上尿路结石发病率 明显提高 如果没有随访及医学干预，尿石症5年内 的复发率高达50% Components of stones 晶体+基质(crystal + matrix) 草酸钙、磷酸钙、磷酸镁铵、尿酸、胱氨酸 上尿路（肾、输尿管）结石多为草酸钙 结石、草酸钙与磷酸钙混合性结石 下尿路结石磷酸镁铵、尿酸铵结石多见 尿石成分及其性质 成分 草酸钙 质地 硬 表 面 色泽 粗糙、不规则 棕褐色 原因 透光否 基因 不透光 易碎 粗糙、不规则 黄色、灰 梗阻 X片上 白、棕色 感染 分层 鹿角状结石 磷酸镁铵 光滑、不规则 黄、棕红 痛风 透光 硬 尿酸 磷酸钙 胱氨酸 韧 光滑蜡样外观 黄棕淡黄 遗传 半透光 Etiology Aspects Extrinsic Factors Intrinsic Factors Heredity Age and Sex Abnormal metaboly Local factors Extrinsic Factors Climatic and seasonal factors Water intake Diet Medication Water intake the volume of water ingested as opposed to that lost by perspiration and respiration the mineral or trace element content of the water supply of the region Diet Protein Increasing the acid in urine Hyperuricosuria Calcium Hypercalciuria Hyperoxaluria Diet Sodium Hypercalciuria Magnesium Inhibit crystallization of Calcium Phosphate reduce calcium oxalate crystalloiduria Vitamins Medications Steroids Vitamins Sulfanilamide Abnormal metaboly Calcium Oxalate Stone Calcium Phosphate Stone Uric Acid Stone Cystine Stone Calcium Oxalate Stone Hypercalciuria (excessive calcium in the urine and kidneys) Absorptive Hypercalciuria Resorptive Hypercaiciuria Renal Hypercalciuria Calcium Oxalate Stone Hyperoxaluria Hyperuricosuria Citrate Calcium Phosphate Stone Pure calcium phosphate stone is quite rare More common in women and are often associated with tubular acidification defects Showing pure calcium phosphate Distal renal tubular acidosis Primary hyperparathyroidism sarcoidosis Uric Acid Stones By-product of purine Typically radiolucent in nature and may not be identified on plain abdominal films Visible on noncontrast CT images Associated calcium deposits, may be partially radiopaque Cystine Stones Cystine can be found in nerves, muscles, and other body tissues Cystinuria cause excessive cystine build up in the urine, lead to cystine stones Occurs in about 1% to 2% of patients with kidney stone disease The condition often runs in families Local Factors Urinary Infection Urinary Obstruction Urinary Eyewinker Local Factors Urinary Tract Infection 产生解脲酶的细菌-变形杆菌感染 尿液中基质增加，促进晶体粘附 感染性结石（磷酸镁铵）形成的条件 pH≥7.2 尿中有氨存在 Local Factors Urinary Obstruction & Anatomic Abnormalities 近端扩张、尿滞留，尿液浓缩，成石物 质过饱和 结石近端产生涡流，成石物质沉淀 梗阻部位妨碍微石排出 尿液滞留继发尿路感染 Local Factors Urinary Tract Eyewinker 可作为核心诱发成石物质沉淀和附着 各种导管、内支架 手术时遗留的丝线 人为塞入膀胱的金属、木条、塑料 尿石形成的影响因素 The influencing Factors of Stone Forming 影响尿路结石形成的因素 Anatomic Abnormalities Urinary Tract Infection Nutrition Status Others 成石机制 Pathogenesis Some Theories 异质成核学说 取向附生学说 结石基质学说 晶体抑制物质学说 Process Nucleation (晶核形成) Crystal Growth (结晶生长) Crystal Aggregation (结晶聚集) Crystal Retention (结晶滞留) Pathogenesis struvite (infection stones) Made of crystallized magnesium and ammonia phosphate common acidic by-products of the bacterial breakdown of urea Pathophysiology 肾和膀胱内形成结石 与结石部位、大小、数目、继发炎症、 梗阻程度等有关 结石排出过程中，可停留在输尿管和尿 道，形成该处结石 Pathophysiology 肾盏结石阻塞肾盂输尿管连接处或输尿管 急性完全性梗阻 解除梗阻，可无肾损害 慢性不完全性梗阻 导致肾积水，影响肾功能 较大肾盂结石对肾实质和肾功能损害轻微 Pathophysiology 输尿管内径自上而下由粗变细-输尿管下 1/3处结石最多见 进入输尿管，常停留嵌顿于生理狭窄处 肾盂输尿管连接处 输尿管跨越髂血管处 输尿管膀胱连接处 输尿管肾盂连接处 ureterpelvic junction 越过髂血管处 over the iliac vessels 输尿管膀胱连接处 ureterovesical junction Pathophysiology 结石损伤尿路粘膜导致出血、感染 梗阻易发生感染 感染、梗阻可促使结石形成及长大 肾盂及膀胱内结石可引起恶变 充满肾盂、部分或全部肾盏：鹿角形结石 (Staghorn) Pathophysiology 结 石 (stone) 梗阻 (obstruction) 感染 (infection) Suspense If urinary constituents are similar from each kidney and if there is no evidence of obstruction, Why do most stones present in a unilateral fashion? Why don't small stones pass uneventfully down the ureter early in their development? Why do some people form one large stone and others form multiple small calculi? Question OR Comment? 上尿路结石 Upper Urinary Tract Calculi Including Nephrolithiasis (Kidney Stones) and Ureteral Calculi Types of Stones calcium salts struvite (infection stones) uric acid cystine Struvite Stones Accounts for up 20% of kidney stones Often occurs in patients who develop urinary tract infections More common in women Typically develops as a "staghorn" Types of Stones - Clinical Renal Calyx Calculi Renal Pelvis Calculi Staghorn Calculi Upper & Mid Ureter Calculi Distal Ureter Calculi Clinical Presentation* Pain & Hematuria associated with activity The character of the pain depends on the stone location, size, movement and complication Renal Colic and noncolicky renal pain are two types of pain originating from kidney Noncolicky renal pain is caused by distention of the renal capsule Symptoms & Signs Renal Colic (肾绞痛) usually is caused by stretching of the collecting system or ureter Urinary obstruction is the main mechanism responsible for renal colic Local mechanism such as inflammation, edema, hyperperistalsis may contribute to the perception of pain Renal (Ureteral) Colic 肾绞痛 Comes on suddenly and acutely Wax and Wane, may be relatively constant Usually starts in the back, at waist or in the flank, stomach or groin Nausea, vomiting, chills, fever Frequently move constantly into unusual position in an attempt to relieve the pain Renal (Ureteral) Colic Radiation of pain ： PUJ or upper ureteral tract obstruction 腰部及上腹部，并沿输尿管行经放射至同侧 睾丸、阴唇和大腿内侧 Midureteral obstruction 中下腹，易与急性阑尾炎混淆 Distal ureter entering vesical, ureteral orifice 伴膀胱刺激症状，尿道/阴茎头放射痛 Radiation of pain with various types of ureteral stone Radiation of pain with various types of ureteral stone Radiation of pain with various types of ureteral stone Hematuria Blood in the urine - another classic symptom The blood may be clearly visible, or may be microhematuria Often, patient’s urine is usually tea-colored and/or cloudy Microhematuria after movement may be the only one symptom Symptoms & Signs 无尿 (anuria) 双侧上尿路结石引起双侧完全性梗阻 独肾上尿路结石完全性梗阻 结石伴感染：frequency、dysuria 继发急性肾盂肾炎或肾积脓 畏寒、寒战等全身症状 有时感染症状可以是尿路结石唯一表现 Diagnosis History Evaluate the nature of the pain, including its onset; character; potential radiation; activities that exacerbate or ease the pain Associate nausea, vomiting Gross hematuria History of similar pain History Typical renal, ureteral colic with hematuria Risk factors Crystalluria Diet Occupation and climate Family history Medications Physical Examination Attempting to find relief in multiple, frequently, bizarre, positions Tachycardia, sweating and nausea An abdominal mass may be palpable in patients with long-standing obstructive urinary calculi & severe hydronephrosis Physical Examination Abdominal Examination should exclude other causes of abdominal pain Examination of abdomen reveals moderate deep tenderness on palpation over the location of the calculus and the area of the loin Diagnosis Stone diagnosis including location, size, number, shape, type Complication diagnosis Urinary infection Degree of obstruction Renal failure Etiological evaluation Laboratory Test Urinalysis (尿液分析) Microscopic or gross hematuria Moderate pyuria or pus cells Gross hematuria may be the only complaint Crystalluria Urine germiculture (尿细菌培养) Laboratory Test Serum biochemistry examination Ca, P, Cr, AKP, Uric acid, Albumen, K, Na, Cl, PTH, etc Analysis of urinary metabolites in 24-hour urine collections Acidified sample - Calcium, Oxalate, Magnesium, Phosphorus Alkaline sample – Uric acid Untreated aliquots - Creatinine Laboratory Test Analysis of Uroliths Chemical analysis – qualitative & semiquantitative Infrared Spectroscopy Binocular Stereoscopic microscope X-ray Diffraction, Electron Microscopy A combination of morphologic and structural examination of stone has shown to provide a cost-effective, precise, and reliable analysis of stone A. Apatite (磷灰石 ) B. Struvite (鸟粪石 ) C. Calcium oxalate Dihydrate (草酸钙) D. Calcium oxalate monohydrate E. Cystine F. Ammonium acid urate Diagnostic Uroradiology Ultrasonography (Type B) Noninvasive method for screening urinary stone Sensitive in detecting radiolucent calculi particularly those measuring 2~3mm in largest dimension small stones Diagnostic Uroradiology Ultrasonography (Type B) Presenting anatomic structure changes and hydronephrosis An echogenic focus with posterior acoustic shadowing False-postive Uretervesical Junction Calculus Radiographic Examination 泌尿系平片(K U B) 95%以上结石可显示 结石过小或钙化程度不高者可不显示 纯尿酸结石及基质结石可不显示 如结石厚度小于2mm则无法分辨 是诊断输尿管结石的最基本方法 区分淋巴钙化、静脉石、骨岛 Radiographic Examination 排泄性尿路造影 （IVU / IVP） 可确诊肾结石 肾结构与功能改变 透光结石可显示充盈缺损 绞痛发作后2周再做 Radiographic Examination Computerized Tomography (CT) 可分辨0.5mm结石 可显示任何成分的结石 螺旋CT可检出90%输尿管结石 输尿管结石表现为高密度影及“框边” 逆行肾盂造影：其他方法不能确定时 输尿管肾镜 可明确诊断并可治疗 检查指征 腹部平片未显示结石 排泄性尿路造影有充盈缺损 Differential Diagnosis Acute abdomen ( peritoneal signs! ) Acute appendicitis Ectopic and unrecognized pregnancies Ovarian pathologic conditions Biliary stones with & without obstruction Peptic ulcer disease Acute renal artery embolism, etc Differential Diagnosis * 有感染时 是感染导致结石抑或结石继发感染？ 是尿路结石还是腹内其他钙化阴影 胆囊结石、肠系膜淋巴结钙化、静脉石 正、侧位摄片 侧位片上尿路结石位于椎体前缘之后 输尿管平片双曝光斜位摄片 treatment 有无确定病因 有无代谢异常 有无梗阻和感染及其程度 结石大小、部位、数目、肾功能和全身 情况 保守治疗 结石小于0.6厘米 直径小于0.4厘米光滑结石90%可自行排出 结石表面光滑 无尿路梗阻，无感染 纯尿酸结石或纯胱氨酸结石 有排石史者 保守治疗 注意观察每次排出尿液，有无结石排出 大量饮水 是预防结石形成和长大最有效的方法 每天保持2000毫升以上 睡前及半夜饮水，保持夜间尿液稀释状态 控制感染：抗生素 保守治疗 饮食调节 限制含钙、草酸成分丰富的食物 钙：牛奶、奶制品、豆制品、巧克力、坚果 草酸：浓茶、番茄、菠菜、芦笋 避免高动物蛋白、高糖、高动物脂肪饮食 食用含纤维丰富食物 尿酸结石忌高嘌呤食物：动物内脏、鱼虾 保守治疗 调节尿液pH值 碱化尿液：枸橼酸钾、重碳酸钠 可预防、治疗胱氨酸结石 预防：尿液保持pH在6.5 治疗：尿液保持pH在7~7.5 酸化尿液：氯化铵 防止感染性结石的生长 保守治疗 中西医结合综合疗法 对于纯尿酸结石-溶石效果最好 大量饮水 饮食调节 碱化尿液 口服别嘌呤醇 保守治疗 感染性结石 控制感染 取除结石 酸化尿液 应用脲酶抑制剂 -乙酰异羟肟酸 保守治疗 胱氨酸结石 碱化尿液，使pH大于7.8 D-青霉胺，-巯丙酰甘氨酸（ -MPG）、 乙酰半胱氨酸可用来溶石 卡托普利可用来预防 肾绞痛：解痉、镇静、镇痛 体外冲击波碎石 Extracorporeal Shock Wave Lithotripsy 多数上尿路结石适用-首选方法 X线、B超定位，冲击波聚焦后作用于结石 适宜于0.5~2.5cm的结石 碎石效果与结石部位、大小、性质、是否 嵌顿等因素有关 击碎结石堆积于输尿管内-石街 再次碎石，间隔时间不少于7天 体外冲击波碎石 禁忌症： 妊娠 – 绝对禁忌 结石远端尿路梗阻 出血性疾病 严重心脑血管病 安置心脏起搏器患者 血肌酐≥265mol/L、急性尿路感染 育龄妇女下段输尿管结石 手术治疗 分为开放手术及非开放手术两类 手术前必须了解双侧肾功能 有感染时应先抗感染治疗 输尿管结石手术，入手术室前需再做腹部 平片，做最后定位 有原发梗阻因素存在时，应同时予以纠正 非开放手术 输尿管肾镜取石或碎石术 适用于中、下段输尿管结石 平片不显影结石 因肥胖、结石硬、停留时间长而不能用ESWL ESWL所致之“石街” 主要并发症：出血、感染、穿孔 经皮肾镜取石或碎石术 （PCNL） 开放性手术 指征 经ESWL和腔内碎石失败者 结石远端有狭窄、梗阻 体积多大的复杂性肾结石 结石导致肾功能丧失，被迫行肾切除 开放性手术 输尿管切开取石术 肾盂切开取石术 肾窦肾盂切开取石术 肾实质切开取石术 无萎缩性肾切开取石术 肾部分切除、肾切除 凝块法肾盂切开取石术 双侧上尿路结石手术原则 双侧输尿管结石：先处理梗阻严重侧，条 件许可，同时取出双侧结石 一侧输尿管结石、对侧肾结石：先处理输 尿管结石 双侧肾结石：根据结石情况及肾功能决定 原则上尽可能保留肾 一般先处理易于取出和安全侧 若肾功能差、梗阻严重、全身情况差：先行 经皮肾造瘘，待改善后再处理结石 双侧上尿路结石手术原则 双侧上尿路结石或孤立肾上尿路结石引起 急性完全性梗阻无尿时 明确诊断后，情况允许，应及时施行手术 病情严重不能耐受手术，可试行输尿管插 管或行经皮肾造瘘 上尿路结石的预防 Prevention 上尿路结石的预防 一般性预防方法 大量饮水 根据结石成分调节饮食 特殊性预防方法 草酸盐结石：VitB6、氧化镁 感染、尿酸、胱氨酸结石：见前述 别嘌呤醇对含尿酸结石有抑制作用 有甲旁亢者，摘除腺瘤或增生组织 尿石症 膀 胱 结 石 Vesical Calculi 病 因 继发性膀胱结石 膀胱出口梗阻 膀胱憩室 神经原性膀胱 异物及长期留置导尿管者 肾结石排至膀胱 诊 断 临床表现 典型症状：排尿中断，并感疼痛，放射 至阴茎头部和远端尿道 伴排尿困难和膀胱刺激症 结石位于憩室内可无上述症状，表现为 尿路感染 诊 断 X线检查：平片可显示大多数结石 B型超声检查 -高回声伴声影，随体位改变 膀胱镜检查- 最可靠方法 直肠指诊能摸到较大的结石 治 疗 采用手术治疗 经膀胱镜机械、超声、激光等碎石 结石过大、过硬或有膀胱憩室者，宜采用耻 骨上膀胱切开取石 应同时治疗病因 膀胱感染严重时，应用抗生素 Urolithiasis 尿道结石 Urethral Calculi Conspectus Majority stones expelled from the kidney & bladder Rarely may form primarily when stricture, pouch or diverticulum presented Usually only a single stone is encountered in anterior urethra Females rarely develop urethral calculi Diagnosis Clinical Presenting Typical symptom： Acute urinary retention associated with severe perineum/rectum pain Pain may radiate to the tip of the penis Intermittent urinary stream Terminal hematuria & infection Diagnosis Confirmed diagnosis : palpation, endoscopic visualization & radiographic study A hard mass could be touched via Digital Rectal Examination in the path of urethra 治 疗 原 则 结石位于尿道舟状窝 注入无菌石蜡油后轻轻推挤，钩取或钳出 前尿道结石尽量不做尿道切开取石 后尿道结石在麻醉下将结石推入膀胱， 再按膀胱结石处理