Urolithiasis disease

Urolithiasis (nephrolithiasis, urolithiasis) is the second most common kidney disease that occurs at any age, characterized by the deposition of stones in the calyx-calcification system of the kidneys and urinary tract. The incidence of nephrolithiasis in industrialized countries is growing in parallel with the spread of obesity and currently stands at 1-2%.

Epidemiology

The risk of developing urolithiasis is 5-10%, the incidence of men is 3 times higher than that of women. Urolithiasis most often occurs in patients aged 40-50 years.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Causes of the urolithiasis

Recently, due to changes in diet, a sedentary lifestyle, the impact of a variety of unfavorable environmental factors of urolithiasis is occurring more often.

Urolithiasis develops due to excessive intake of animal protein and salt, potassium and calcium deficiency, obesity, alcoholism, genetic, environmental factors.

The secretion of urate and calcium is disrupted by lead and cadmium intoxication. In 40-50% of patients with frequently recurrent calcium nephrolithiasis, hypercalciuria with an autosomal dominant type of inheritance was detected.

[10], [11]

Risk factors

For patients with any form of urolithiasis, it is necessary to analyze the causes of stone formation for the purpose of subsequent treatment or removal of the stone. It should be noted that none of the types of surgical intervention, in fact, is not a method of treating urolithiasis, but only relieves the patient of the stone.

The factors that increase the risk of stone formation

Factor	Examples
Urolithiasis in a family history
Living in endemic regions
Monotonous food, rich in substances that promote stone formation
Deficiency in food of vitamin A and Vitamins of group B
Medications	Calcium preparations; Preparations of vitamin D; Ascorbic acid (more than 4 g per day); Sulfonamides
Anomalies of the urinary system	Tubular ectasia; stricture (narrowing) of LMS; diverticulum calyx; cyst cup; stricture of the ureter; vesicoureteral reflux; ureterocele; horseshoe kidney
Diseases of other systems	Hyperparathyroidism; Renal tubular acidosis (total / partial); Itino-ileacic anastomosis; Crohn's disease; Condition after resection of the ileum; Malabsorption syndrome; Sarcoidosis; Hyperthyroidism

So, among the factors influencing the formation of calcium-oxalate stones, often endocrine system (parathyroid gland), gastrointestinal and kidney (tubulopathy) diseases. Violation of purine metabolism leads to the development of urate nephrolithiasis.

Chronic inflammatory diseases of the genitourinary system can promote the formation of phosphate (struvite) stones.

Thus, depending on the etiological factors and developing metabolic disorders, various urinary stones are formed according to the chemical composition.

[12], [13], [14], [15], [16], [17], [18], [19]

Pathogenesis

There are several theories of stone formation.

• According to the matrix theory, the desquamation of the epithelium results from the development of an infectious disease of the urinary system to lay the nucleus of the emerging stone.
• The colloid theory is based on the transition of protective colloids from the lipophilic form to the lipophilic form, which creates favorable conditions for pathological crystallization.
• Ionic theory justifies the formation of stones with the inadequacy of urine proteolysis under conditions of a changed pH.
• The theory of precipitation and crystallization considers the formation of a stone in a supersaturated urine with an intensive crystallization process.
• The inhibitory theory explains the formation of stones by a violation of the balance of inhibitors and promoters that support metastability of urine.

All the theories of stone formation are united by the basic condition - a violation of the metastability of urine and the supersaturation of urine by stone-forming substances.

Reduced absorption of calcium in the renal tubules and excess in the gastrointestinal tract along with accelerated resorption of bone tissue is caused by a genetically predetermined increase in the number of cellular receptors to calcitriol. A young genetically inherited urate calcium lythiasis with hypertension is described, which is based on the tubular defect of calcium excretion and Na reabsorption. Genetic disorders cause the most severe forms of nephrolithiasis with oxalose, cystinosis, Lesch-Naikhan syndrome, type I glycogenesis.

The pathogenesis of urolithiasis is associated with impaired renal acidogenesis, combined with an increase in renal excretion or excessive absorption in the digestive tract forming the concrement of metabolites. Excess intake of animal protein leads not only to hyperuricosuria, but also to an increase in the synthesis of oxalic acid (hyperoxaluria) and hypercalciuria.

Abuse of sodium chloride or a deficiency in potassium food also leads to hypercalciuria (due to increased absorption of calcium in the digestive tract and admission from bone tissue), hyperoxaluria and decreased excretion of citrates, inhibitors of stone growth, and also increases osteoporosis. Alcohol induces hyperuricaemia (intracellular decay of ATP, decrease in tubular secretion of urates) and hypercalciuria.

In addition to hyperexcretion of these stone-forming salts, in the pathogenesis of nephrolithiasis an important role is played by persistent pH shift of urine, dehydration and oliguria, disturbances of urodynamics (vesicoureteral reflux, pregnancy, intestinal atony).

A unified classification based on the chemical composition of urinary stones, the clinical form of the disease and various factors promoting stone formation, revealed in the patient's anamnesis, has been created to understand the process of stone formation and the selection of the optimal treatment regimen.

The process of formation of the urinary stone can be prolonged, often without clinical manifestations; can be manifested by acute renal colic, caused by the escape of microcrystals.

[20], [21], [22], [23], [24], [25],

Classification of urinary calculi

• Urinary stones of inorganic nature:
  • calcium-oxalate (leads, leads); calcium-phosphate (whitlockite, brushite, apatite, carbonatopatite, hydroxyapatite), calcium carbonate. Calcium urinary stones are found in 75-85% of cases of urolithiasis; more often in men older than 20 years; relapse noted in 30-40% of cases, with brushite stones - in 65%). Magnesium-containing urinary stones are found in 5-10% of cases (neuberite, magnesium ammonium phosphate monohydrate, struvite), which are detected in 45-65% of cases, more often in women with infectious diseases of the genitourinary system (vevelit, vedelit, brushit). Struvitis has a high risk of developing inflammatory complications. Relapses occur in 70% of cases with incomplete removal of urinary stone or in the absence of treatment of urinary infection.
• Urinary stones of organic nature:
  • At a constantly low pH of urine (5,0-6,0) urinary stones are formed from uric acid and its salts (ammonium urate, sodium urate, uric acid dihydrate), and their frequency increases with age. Urinary urinary stones (5-10% of cases of urolithiasis) are more often formed in men. Metaphylactics reduces the risk of relapse completely.
  • At a urine pH of less than 6.5, the rarest proteinaceous urinary stones (cystine, xanthine and others) are formed, representing 0.4-0.6% of cases of urolithiasis and associated with congenital metabolic disorders of the corresponding amino acids in the patients. Relapses reach 80-90%. Prevention is extremely complex, often ineffective.

However, in pure form, stones occur in about 50% of cases, and in the rest - in the urine are formed mixed (polymineral) in composition in various versions of urinary stones, characterized by parallel various metabolic and often joined infectious processes.

[26], [27], [28]

Symptoms of the urolithiasis

Symptoms of urolithic illness are characterized by a pain syndrome of varying degrees of intensity, chronic course, frequent adherence of pyelonephritis, an outcome in chronic renal failure with bilateral lesion.

• Lohan Nephrolithiasis. It is caused by the deposition of small concrements in the renal pelvis. Observe the recurrent course with repeated attacks of painful pains caused by acute obstruction of the urinary tract by concrement, renal colic with hematuria.
• Plaque-pelvis (coral) nephrolithiasis. The most severe, rarer form of nephrolithiasis is caused by a calculus occupying the entire calyx-pelvis system. With coral nephrolithiasis, renal colic does not develop. Periodically disturb low-intensity pain in the lower back, pain in the right side, occasionally reveal macrogematuria, especially often secondary pyelonephritis, slowly progressing chronic renal failure.
• Acute complications. Include secondary (obstructive) pyelonephritis (see "Pyelonephritis"), postrenal acute renal failure, fornal bleeding.
• Chronic complications. With unilateral nephrolithiasis lead to atrophy of the kidney parenchyma due to its hydronephrosis transformation, as well as to the formation of pionephrosis, and renovascular hypertension. The outcome of bilateral nephrolithiasis is often the wrinkling of the kidneys with the development of terminal chronic renal failure.

Symptoms of urolithiasis, although rare, can be absent for a certain period of time, and the stone can be detected accidentally with x-ray or ultrasound. This so-called latent form of the chronic phase of urolithiasis does not depend on the size of the stone, but is determined mainly by localization, mobility and the presence or absence of infection. For example, a large stone localized in the kidney parenchyma, without disturbing the intraocular urodynamics and lack of secondary infection, can exist for a long time without causing symptoms of urolithiasis.

However, often the only complaint in a significant number of patients with such stones is dull pain in the lower back, which is explained by the involvement of the fibrous capsule of the kidney in the inflammatory process. At the same time, a small but mobile stone in the pelvis, violating the outflow of urine from the kidney, most often gives a severe clinical picture with significant changes in the renal function of the kidney.

Renal colic is the main symptom of urolithiasis

Expressed forms of the disease have characteristic symptoms of urolithiasis. The most common symptom in these cases is pain, often manifested as an attack of renal colic. It is characterized by a sudden onset acute pain in the lower back on the side of the lesion, with a typical irradiation along the anterior wall of the abdomen down the ureter to the bladder and genital organs. Sometimes the pain can cover the entire abdomen or be most pronounced in the contralateral healthy kidney. Patients with renal colic are in motor excitement, continuously changing their position.

Further, symptoms such as dysuria, nausea, vomiting, flatulence, abdominal wall tension, simulating a picture of an acute abdomen may appear. These signs can also be accompanied by chills, fever to subfebrile digits, slowed-down soft pulse, rapid breathing, dry mouth. Usually, an attack of renal colic lasts several hours, but it may not take several days. Termination of the sick can occur both suddenly and with a gradual regression of symptoms. The cessation of pain can be explained either by changing the position of the stone, or by its withdrawal from the ureter and by the restoration of the outflow of urine from the kidney.

The cause of renal colic is mechanical obstruction of the ureter, accompanied by spasm of its wall and an increase in intra-local pressure, which in turn causes an acute dilatation of the pelvis and stagnant processes in the kidney, causing the fibrous capsule to stretch and irritate the rich network of nerve endings.

Symptoms of urolithiasis, which simulate renal colic disease of the abdominal cavity organs (acute stomach) ( flatulence, abdominal wall tension, nausea, vomiting, etc.) is a consequence of reflex reactions of adjacent innervated organs and is often caused by pronounced paresis of the intestine.

The increase in body temperature, leukocytosis and other common manifestations of renal colic are caused by a pulmonary-renal reflux.

Still characteristic symptoms of urolithiasis are hematuria. It occurs in all phases of the disease, except for the period of complete obstruction of the ureter. For hematuria in urolithiasis, a characteristic difference is that hematuria often increases during movement and decreases at rest. This hematuria is not abundant, most often it is detected in the form of microhematuria; usually without the formation of blood clots.

Leukocyturia and pyuria are important symptoms indicating a complication of urolithiasis by infection. However, with aseptic stones in the general analysis of urine, it is often possible to detect up to 20-25 white blood cells in the field of vision.

Spontaneous removal of the stone with urine is the most reliable symptom proving the presence of the disease. Usually the stone is preceded by an attack of renal colic, an increase in blunt pain or dysuria.

In the phase of remission of urolithiasis symptoms may not manifest and when prescribing preventive treatment the doctor bases on the survey data.

Forms

With coral nephrolithiasis, the calculus entirely performs the cup-and-pelvis system. There are calcium (carbonate), oxalate, urate, phosphate nephrolithiasis. Less common are cystine, xanthine, protein, cholesterol stones.

The clinical form of urolithiasis determines the severity of the course of the disease and the choice of the method of treatment.

Depending on the shape and location of the urinary stone in the urinary system, a clinical classification was developed.

• By number of stones:
  • single urinary stone;
  • multiple urinary stones;
  • coral urinary stones.
• By frequency of occurrence:
  • primary;
  • recurrent (true-recurrent, false-recurrent);
  • residual.
• The nature:
  • infected;
  • uninfected.
• By localization of urinary stone:
  • calyx;
  • a rock
  • bilateral urinary stones of calyx;
  • upper third of the ureter;
  • middle third of the ureter;
  • lower third of the ureter;
  • Bladder;
  • urethra.

In the European associations of urologists, it is customary at the time of diagnosis that urinary stones of ureters indicate one of the three zones of their localization (upper, middle and lower third); in the American Association - one of the two, the upper or lower.

[29], [30], [31], [32],

Diagnostics of the urolithiasis

Carefully collected history allows in 80% of cases to choose the right direction of diagnosis of urolithiasis. When dealing with a patient, special attention is paid to possible risk factors. In a physical examination involving palpation, it is possible to identify the painfulness of the affected kidney by tapping the waist (a positive symptom of Pasternatsky).

Patients with renal colic caused by stone failure, as a rule, complain of intense paroxysmal pain in the lower back, nausea, vomiting, chills, subfebrile body temperature. When the stone is localized in the lower third of the ureter, patients experience imperative urges for urination, irradiation of pain in the inguinal region. Clinical diagnosis is established according to various methods of visualization of stones (radiation diagnosis).

It should be noted that the diagnosis of urolithiasis is based on imaging methods, since the physical urological symptoms of urolithiasis are characteristic of many diseases. Often, renal colic must be differentiated with acute appendicitis, cholecystitis, colitis, radiculitis, etc. Modern diagnosis of urolithiasis in 98% of clinical observations can correctly diagnose various clinical forms of urolithiasis.

[33], [34], [35]

Laboratory diagnosis of urolithiasis

A general blood test allows you to judge the signs of the inflammation that has begun: note leukocytosis, a shift of the leukocyte formula to the left with an increase in the number of stab neutrophils, an increase in ESR.

In the clinical analysis of urine, micro- or macrohematuria, crystalluria, leukocyturia, bacteriuria, urine pH change are detected.

[36], [37]

Laboratory studies in uncomplicated course of urolithiasis

Analysis of the chemical composition of the stone

• Must be performed in each patient

Blood chemistry

• Determine the concentration of free and ionized calcium, albumin; as additional indicators - the concentration of creatinine, urate

[38], [39]

Analysis of urine

Analysis of morning urine with sediment:

• studies using a special test system (pH, number of leukocytes, bacteria, cystine content, if cystinuria can not be excluded by other methods);
• a study of the culture of bacteria in the detection of bacteriuria

[40], [41], [42], [43], [44], [45]

Studies in the complicated course of urolithiasis

Analysis of the chemical composition of the stone

• Must be performed in each patient

Blood chemistry

• Determine the concentration of free and ionized calcium, albumin; as additional indicators - the concentration of creatinine, urate, potassium

[46], [47], [48], [49], [50], [51]

Urinalysis

Analysis of morning urine with sediment:

• studies using a special test system (pH, number of leukocytes, bacteria, level of cystine, if cystinuria can not be excluded by other methods);
• a study of the culture of bacteria in the detection of bacteriuria.

 Daily urine test:

• determination of the concentration of calcium, oxalates, citrates;
• determination of urate concentration (in samples not containing an oxidizer);
• determination of creatinine concentration;
• determination of the volume of urine (diuresis daily);
• determination of magnesium concentration (additional analysis, necessary for determining ionic activity in products of ionized Ca);
• determination of phosphate concentration (additional analysis, necessary for determining ionic activity in calcium phosphate products, concentration depends on the patient's dietary preferences):
• determination of the concentration of urea, potassium, chloride, sodium (additional analyzes, concentrations depend on the patient's dietary preferences)

Qualitative and quantitative analyzes of urinary stones are carried out using infrared spectrophotometry and X-ray diffractometry. Analysis of the elemental and phase composition of urinary calculus is an indispensable element of modern diagnosis of urolithiasis, since knowledge of the chemical structure to the pathogenesis of the disease and the metabolic disturbances that have arisen in the body makes it possible to develop adequate medication conservative therapy.

Instrumental diagnosis of urolithiasis

Mandatory examination includes an overview radiograph of the abdomen (area of the kidneys, ureters and bladder). The method allows to diagnose X-ray stones. The sensitivity of the method is 70-75% (it can decrease with aerocosy, increased weight of the patient), the specificity is 80-82%.

Kidney ultrasound can be judged in:

• direct representation of a stone in the kidney and the pre-tubercular department of the ureter;
• an indirect idea of the expansion of the cup-and-pelvic system, the proximal and distal ureter.

Ultrasound can evaluate edema of the parenchyma, reveal foci of purulent destruction and an index of resistance of the renal arteries. The diagnostic significance depends on the class of ultrasound equipment and the professionalism of the doctor, on average the sensitivity of the kidney ultrasound is 78-93%. Specificity is 94-99%.

Excretory urography is performed after complete relief of renal colic. The method gives an adequate idea of the anatomical and functional state of the urinary system. The interpretation of the results is influenced by the same factors as the survey image. The sensitivity of the method is 90-94%. Specificity - up to 96%.

Excretory urography is not prescribed for patients:

• taking metformin;
• patients with myelomatosis;
• with an allergic reaction to contrast agent;
• with a serum creatinine level of more than 200 mmol / l.

MSCT perform when:

• suspicion of urate nephrolithiasis;
• complex form of corneal nephrolithiasis;
• the occurrence of a suspected urinary tract tumor;
• If the stone is not diagnosed by other methods of investigation

MSCT allows virtual reconstruction of the images and to assess the density of the stone, which, in turn, helps to determine the indications or contraindications to the conduct of DLT.

The sensitivity and specificity of the method are close to 100%.

Additional examination includes:

• retrograde or antegrade ureterography, pyelography (allow to diagnose ureteral permeability all along);
• dynamic scintigraphy for separate and segmental studies of secretory and evacuation function of the kidneys;
• aortography for the analysis of angioarchitectonics of the kidney, which is especially important in the planning of repeated operations (2-3 operations) for coral nephrolithiasis, when conflicts with the vessels are possible with their allocation.

Indications for consultation of other specialists

For more effective treatment it is very important to send a patient to the endocrinologist, dietician, gastroenterologist in time.

Example of the formulation of the diagnosis

Correctly formulated diagnosis allows the specialist to provide the most complete picture of the disease. Till now often it is necessary to collide or meet with extracts in which the diagnosis sounds so: "A stone of a right kidney. Chronic pyelonephritis".

At the same time, using the accepted classification of urolithiasis and a comprehensive examination of the patient, this diagnosis should be formulated as follows: "Primary single oxalate stone of the pelvis (2.0 cm) of the functionally preserved uninfected right kidney";

"Falsely recurrent, clinically inconspicuous urate stone (size, diameter up to 6 mm) of an isolated lower calyx of a second wrinkled right kidney."

In addition, a single consistent statement of the diagnosis is a prerequisite for the transition of domestic health care to insurance medicine.

[52], [53], [54]

Differential diagnosis

Differential diagnosis of urolithiasis and renal colic, complicated by obstructive pyelonephritis, is performed with:

• acute appendicitis;
• acute cholecystitis;
• perforated ulcer of the stomach or duodenum;
• acute obstruction of the small or large intestine;
• acute pancreatitis;
• ectopic pregnancy;
• diseases of the spine.

A distinctive feature in the urological nature of the disease is the absence of symptoms of irritation of the peritoneum seen in diseases of the gastrointestinal tract.

[55], [56], [57], [58], [59]

Treatment of the urolithiasis

Treatment of urolithiasis begins immediately after the occurrence of a relapsing nature of pain, avoid the use of morphine and other opiates without the simultaneous administration of atropine.

Drug treatment of urolithiasis

Treatment of urolithiasis begins immediately after the occurrence of a relapsing nature of pain, avoid the use of morphine and other opiates without the simultaneous administration of atropine.

To stop the pain syndrome, various combinations of the following drugs can be used: diclofenac, indomethacin, ibuprofen, morphine, metamizole sodium and tramadol.

Diclofenac reduces the rate of glomerular filtration in patients with renal insufficiency; in patients with normal renal function this does not occur.

In the event that the calculus can independently move away, 50 mg of diclofenac in suppositories or tablets are administered twice a day for 3-10 days to relieve pain, reduce the risk of recurrence, reduce edema of the ureter. The movement of the calculus and evaluation of the functional parameters of the kidneys should be confirmed by appropriate methods.

According to the European Association of Urologists at a concrement size of 4-6 mm, the probability of spontaneous divorce is 60%:

• the upper third of the ureter - 35%;
• middle third of the ureter - 49%;
• the lower third of the ureter - 78%.

According to the American Urological Association, in 75% of cases the stones of the ureter depart spontaneously:

• at concrements up to 4 mm - 85%;
• with stones more than 4-5 mm - 50%;
• stone more than 5 mm - 10%.

However, small stones (up to 6 mm) can be an indication for prompt removal in the following cases:

• no effect, despite adequate treatment of urolithiasis;
• chronic obstruction of the urinary tract with a risk of impaired renal function;
• infectious diseases of the urinary tract;
• inflammatory process, risk of development of urosepsis or bilateral obstruction.

[60], [61], [62], [63], [64], [65], [66], [67]

Operative treatment of urolithiasis

The main recommendations for the removal of concrements

Patients who are planning to remove the calculus are prescribed:

• sowing urine;
• the study of the isolated culture of bacteria on the sensitivity to antibiotics;
• general clinical analysis of blood;
• creatinine clearance.

If the bacteriuria test is positive or a bacterial growth or infection is detected in the urine culture, the patient is prescribed antibiotics before the operation. When confirming a clinically significant infectious disease or in the case of obstruction of the urinary tract, the kidney is drained through stenting or percutaneous puncture nephrostomy for several days before the operation.

Remote lithotripsy, percutaneous lithotripsy, ureteroscopy and open surgery are contraindicated in patients with hemostatic system disorders.

Indications for active removal of concrements

The size, shape, location of the calculus and the clinical course of the disease determine the strategy for the treatment of urolithiasis. Clinically not showing a single calyx stone (up to 1.0 cm) or calyx coral stone, which do not disturb the secretory and evacuation functions of the kidney and do not lead to the progression of pyelonephritis, are not an indication for their rapid removal. At the same time, any stone that causes pain to the patient, social discomfort that disrupts the urinary system, leading to the death of the kidney, is an indication for its rapid removal.

Remote shock wave lithotripsy

It is often necessary to perform several sessions of remote lithotripsy when used as a monotherapy (remote lithotripsy in situ). Large and "punctured" stones (more than 4-6 weeks long) located in one place of the ureter require the maximum number of sessions of remote lithotripsy and the application of additional therapeutic measures, so contact ureterolithotripsy comes to the fore in this situation. To date, the American and European Association of Urologists have developed a fundamentally unified tactic in choosing a method for removing ureteral calculi.

Video endoscopic retroperitoneal surgery is a minimally invasive alternative to open surgery, although both of these methods are shown only when remote lithotripsy and contact ureterolithotripsy are not feasible. At the same time, assessing the effectiveness of remote lithotripsy and contact ureterolithotripsy separately and their combination. Allowing to achieve the removal of ureteral stones with an efficiency of up to 99%, indications for laparoscopy and open surgery to date - extremely rare.

Principles of active removal of kidney stones

The success of remote lithotripsy depends on the physico-chemical properties of the calculus and the anatomical and functional state of the kidneys and upper urinary tract. Remote shock wave lithotripsy is a non-invasive and least traumatic method for removing urinary stones.

All modern lithotripters, regardless of the source of shock wave generation, create a shock wave impulse that, without traumatizing biological tissues, has an alternating effect on the stone, gradually leading to its destruction to finely dispersed mass, followed by spontaneous descent through the urinary tract.

In 15-18% of cases, the remaining fragments of stone up to 3-4 mm in size are noted, which leads to the formation of a "stone path" in the ureter.

Optimum for carrying out remote lithotripsy is considered concrements up to 2.0 cm. For larger stones, a preliminary installation of the internal Stent catheter before remote lithotripsy is recommended in order to avoid the accumulation of fragments of the calculus in the ureter.

A prerequisite for increasing the efficiency and reducing the traumatism of a remote lithotripsy session is the perfect precise removal of the stone into the focal zone under X-ray or ultrasound guidance.

Comparative table of methods for visualization and focusing of a stone

Method	Benefits	Disadvantages
X-ray examination	Ease of implementation The ability to obtain a full image of the kidney and ureter, as well as observe the degree of destruction of the stone and the displacement of fragments	Irradiation of patient and staff Dependence of the result obtained on the patient's body weight, as well as on aerosol
Ultrasound	Absence of radiation. Constant control of the process of crushing stone. X-ray-negative stones visualization Small stones are better visible	More complex implementation It does not allow to obtain an image of the middle third of the ureter and fully observe the process of fragmentation of the stone

The fragmentation of one stone in size up to 2 cm in an adult requires 1500-2000 pulses (1-2 sessions); in children 700-1000 pulses, because almost all stones have a lower density.

Mixed concrements are destroyed more easily than monostructured stones. The most difficult to fracture cystine stones.

Stones of larger size require the use of higher energy pulses and several shredding sessions or the implementation of remote lithotripsy after the pre-installation of a Stent catheter or percutaneous nephrolithotripsy.

The measures that ensure the effectiveness of remote lithotripsy include:

• special training of a doctor;
• correct appointment of remote lithotripsy (optimal size of stones up to 2.0 cm);
• accuracy of removing the stone into the focal zone of the shock wave during the session;
• initial knowledge of the physico-chemical properties of the stone and the functional state of the kidney;
• compliance with the technology of using shock wave impulses.

Contraindications to the appointment of remote lithotripsy:

• the possibility of deducing a calculus into the focus of a shock wave (obesity, deformation of the musculoskeletal system);
• violation of the blood coagulation system;
• severe intercurrent diseases of the cardiovascular system;
• acute gastrointestinal diseases;
• inflammatory diseases of the urinary tract;
• strictures below the location of the stone;
• marked decrease in kidney function (more than 50%).

When carrying out remote lithotripsy, complications are very rare; sometimes, ureter obstruction with fragments of the destroyed stone (18-21%), obstructive pyelonephritis (5.8-9.2%), kidney hematoma (0.01%).

For the prevention and elimination of complications:

• spend sanation of the urinary tract before the remote lithotripsy;
• clearly observe the methods of conducting remote lithotripsy, taking into account the clinical course of urolithiasis;
• with a complicated form of urolithiasis, a catheter is preset or a puncture nephrostomy is performed;
• in a timely manner, drain the kidney in the development of obstructive complications.

Contact ureterolitotripsiya

Endoscopic transurethral and percutaneous lithotripsy and lithoextraction allow under simultaneous visual control not only to destroy but also to remove the entire stone, and also to eliminate unextended obstruction below the location of the stone - balloon dilatation, endoureterotomy, endopyelotomy. The effectiveness of endoscopic methods in the removal of concrements is not inferior to remote lithotripsy, and even larger than large stones and complex stones. Until now, the debates about choosing a method for removing large-sized kidney stones have not abated: remote lithotripsy or contact ureterolithotripsy?

However, the complexity of performing transurethral contact ureterolithotripsy in prostatic adenoma, ureteral deviations, and a relatively high percentage of complications lead to the use of remote lithotripsy.

In addition, contact ureterolithotripsy in children (especially in boys) is undesirable, and in 15-23% of cases this procedure (especially with concrements of the upper third of the ureter) stones migrate to the kidney, which requires further remote lithotripsy.

At the same time, contact ureterolithotripsy in 18-20% of cases allows to eliminate the "stone paths" that are formed after the remote lithotripsy. Thus, remote lithotripsy and contact ureterolithotripsy are modern complementary minimally invasive methods for removing ureteral stones, which allows achieving 99% efficiency.

The development of flexible and thin rigid endoscopes and less traumatic lithotripters ("Lithoclast", laser models) contributed to a reduction in the number of complications and increased the effectiveness of contact ureterolithotripsy.

Complications and failures of contact ureterolithotripsy include:

• impossibility of bringing the ureteroscope to the stone (pronounced deviation, periureteritis below the site, bleeding), migration of the stone to the kidney (10-13%);
• traumatization of the ureteral orifice during the bougie stage (1-3%);
• perforation of the ureter as a conductor and ureteroscope (3.8-5 o),
• acute pyelonephritis as a result of undiagnosed infectious diseases of the urinary system, increased pressure of the irrigation solution, non-compliance with asepsis (13-18%);
• acute prostatitis (4%);
• ureteral laceration (0.2%).

For the prevention of complications following conduction of ureterolithotrypsy, a number of requirements are observed.

• The operation is certified qualified with sheets.
• Complex and anti-inflammatory preoperative preparation for contact ureterolithotripsy.
• Preoperative drainage of the kidney in percutaneous lithotripsy in cases of long standing and large ureteral stones with urethrohydronephrosis above the location of the calculus.
• the use of a guidewire with ureteroscopy is mandatory.
• it is necessary to conduct the drainage of the kidney with a catheter or stent after contact ureterolithotripsy for 1-3 days. With a short contact ureterolithotripsy, surgery without bougie mouth and atraumatic removal of a small stone catheter can not be established.

Therapy of complications that occurred after contact ureterolithotrypsy:

• mandatory drainage of the kidney by puncture nephrostomy and the installation of an internal stent;
• active anti-inflammatory detoxification therapy on the background of drainage in the development of acute pyelonephritis;
• open surgery (ureteroureteroanastomosis, nephrostomy and intubation of the ureter) with ureteral detachment.

Percutaneous nephrolithotripsy and litho-enlargement

Percutaneous nephrolithotripsy and lithoextraction are the most effective method of removing large, coral and complicated kidney stones.

The shortcomings of percutaneous nephrolithotripsy include its invasiveness. The need for anesthesia and trauma both at the stage of drainage of the kidney, and directly in the session. As a consequence, the risk of complications is high, especially at the stage of mastering the method.

Perfection of endoscopic equipment and tools for drainage of the kidney allowed to significantly reduce the risk of traumatic complications. Qualified training of a urologist, knowledge of topographic anatomy and possession of ultrasound diagnostic methods are mandatory for effective operation, since the effectiveness of the result of percutaneous nephrolithotripsy and the percentage of complications depend on the most crucial stage of the operation - creation and blocking of the working path (drainage of the kidney).

Depending on the location of the stone, the entrance to the pelvis is through the lower, middle, or upper group of cups.

At coral or multiple concrements it is possible to carry out two puncture canals. To facilitate the visualization of the pelvis and to prevent the migration of the destroyed fragments to the ureter, catheterization of the pelvis is performed before the operation with the pyelography. Using electrohydraulic, ultrasonic, pneumatic, electropulse or laser lithotripter, destroy the stone and simultaneously perform lithoextraction of the fragments. A special casing allows, not losing the nephrotomic stroke, not only to remove large fragments, but prevents the increase of intra-venous pressure.

Development of miniature endoscopic instruments allowed to significantly expand the indications for the use of percutaneous nephrolithotripsy, even in children of younger age group.

According to prof. A.G. Martova (2005), the efficacy of percutaneous nephrolithotripsy in children with coral calculi was 94%. Percutaneous nephrolithotripsy in children is performed only by endoscopists. Having a sufficiently large experience of performing percutaneous operations in adults.

The operation ends with the installation through the nephrotomic course of nephrostomy drainage of the Folley or Mallek type with a diameter not less than the diameter of the nephroscope.

The complications of percutaneous nephrolithotripsy during the puncture stage include:

• puncture through the pelvis or interstitial space;
• wounding of large vessels at the time of puncture or bougie;
• injury of the pleural cavity or organs of the abdominal cavity, through perforation of the pelvis;
• formation of subcapsular or parainal hematoma.

At the stage of performing percutaneous nephrolithotripsy and after it the following complications are possible:

• loss of nephrotomy and the need for repeated puncture;
• injury of the mucous pelvis or interstitial space with the development of bleeding;
• creating uncontrolled increased pressure in the pelvis;
• acute pyelonephritis;
• tamponade pelvis with blood clots;
• Departure or inadequate function of nephrostomy drainage.

To prevent complications after carrying out percutaneous nephrolithotripsy, a number of requirements are observed.

• It is necessary to conduct qualified certificated training of specialists in endourology.
• Possession of the ultrasound diagnostic technique minimizes the percentage of complications at the stage of puncture.
• Installation in the pelvis of the insurance string allows you to become a nephrotomic move in any situation.
• Uncontrolled management of irrigation solutions is unacceptable.
• Preoperative antibacterial treatment of urolithiasis, compliance with asepsis rules and an adequate function of nephrotic drainage reduces the risk of acute pyelonephritis to zero.

With the development of progressively increasing hematomas, bleeding or purulent-destructive pyelonephritis, open surgical intervention (renal revision, suturing of bleeding vessels, kidney decapsulation) is shown.

For stones larger than 2.0 cm or high-density concrements that do not respond well to DLT, percutaneous stone removal is the best alternative for the treatment of urolithiasis. The effectiveness of a single-stage PNL reaches 87-95%.

For removal of large and coral stones, a high percentage of effectiveness is achieved by combined use of percutaneous nephrolithotripsy and DLT - 96-98%. At the same time, the low density of urinary stones and the high efficacy of DLT, the rapid separation of fragments along the urinary tract, make the method a priority even in the fragmentation of large calculi of the kidneys. The study of long-term results (5-8 years) of DLT in children did not reveal any traumatic kidney injury.

In those cases where minimally invasive methods (DLT, contact ureterolithotrypsy, percutaneous nephrolithotripsy) can not be prescribed for technical or medical reasons, patients undergo an open surgery:

• pyelolithotomy (anterior, posterior, inferior);
• pyelonephrolithotomy;
• anatrophic nephrolithotomy;
• ureterolithotomy;
• Nephrectomy (with wrinkled kidney, pionerophosis, multiple carbuncles or kidney abscesses).

Complications of open operations can be divided into general and urological. Common complications include aggravation of concomitant diseases: IHD (5.6%), gastrointestinal bleeding (2.4%), pleuropneumonia (2.1%), thromboembolism (0.4%).

The greatest attention is attracted to intraoperative complications: iatrogenic injuries of nearby organs (9.8%), bleeding in excess of 500 ml (9.1%), acute pyelonephritis (13.3%), urinary retention (1.8%), suppuration of the operating room wounds (2.1%), postoperative strictures (2.5%).

Preventive maintenance of complications after carrying out of open operations:

• performance (especially repeated operations) by highly qualified urologists contributes to minimal traumatization of the renal parenchyma during surgery;
• conduction of pyelonephrolithotomy with a clamped renal artery;
• adequate drainage of the kidney by nephrostomy drainage of sufficient diameter 16-18 SN with fixation of it to the parenchyma and skin;
• hermetic suturing of the incision of the renal pelvis, ligation of the wounded vessels;
• careful care and supervision of nephrostomy drainage.

The highest percentage (up to 75%) of complications is observed with repeated operations. When due to cicatricial processes, the topographic anatomy of the retroperitoneal space changes.

Treatment of urolithiasis of the calcium form

Treatment of urolithiasis must begin with conservative measures. Pharmacological treatment is prescribed only when the conservative regime is ineffective.

For a healthy adult, the daily amount of urine should be 2000 ml, but the urine hyper saturation index should be used, reflecting the degree of dissolution of the stone-forming substances in it.

The diet should contain a variety of products, different in chemical composition; it is necessary to avoid over-nutrition. Recommendations for nutrition should be created taking into account individual violations of the exchange of each patient.

The use of thiazides increases the reabsorption of calcium in the proximal and distal tubules, reducing urinary excretion. An alternative is the use of orthophosphates (crystallization inhibitors) and prostaglandin inhibitors (diclofenac, indomethacin). The appointment of sodium bicarbonate (4-5 mg per day) is recommended for patients whose treatment of urolithiasis with citrate mixtures did not give a proper result.

Patients who have found stones consisting of magnesium-ammonium phosphate and carbonatopatite and caused by urease-producing microorganisms. During the operation it is necessary to achieve the fullest removal of stones. Antibiotic treatment of urolithiasis should be prescribed in accordance with the data of urine culture; long courses of antibiotic therapy are recommended for maximum sanitation of the urinary tract.

Treatment of urolithiasis of urate form

Prevent the formation of stones from uric acid can, by assigning the patient the use of more liquid (diuresis should be more than 2000 ml per day). Normalization of uric acid levels can be achieved by strict adherence to diet. The increase in plant products and the reduction of meat products containing a high concentration of purines will prevent the relapse of stone formation.

To alkalinize urine, 3-7 mmol of potassium bicarbonate or / and 9 mmol of sodium citrate are administered twice or thrice a day. In cases where the serum level of urate or uric acid is increased, 300 mg of allopurinol per day is used. To achieve the dissolution of stones consisting of uric acid, it is necessary to prescribe intake of a large amount of oral fluid, as well as 6-10 mmol of potassium bicarbonate and / or 9-18 mmol of sodium citrate three times a day and 300 mg of allopurinol in cases where urate levels in the serum and urine are normal.

The chemical dissolution of stones from ammonium urate is impossible.

Treatment of urolithiasis of cystine form

Consumption of liquid per day should be more than 3000 ml. To achieve this, you need to drink 150 ml of liquid every hour. Alkalization should be carried out until the pH of the urine does not stably exceed the value of 7.5. This can be achieved by applying 3-10 mmol of potassium bicarbonate. Divided into 2-3 doses.

Indications for consultation of other specialists

The formation of concrements in the urinary tract is a pathological condition that affects people of different age groups in most countries of the world. Recurrent nature of the disease, often severe complications and disability of patients attach great medical and social significance to this disease.

Patients with urolithiasis should be under constant follow-up care and undergo treatment of urolithiasis for at least 5 years after complete removal of the stone. Correction of metabolic disorders should be carried out by urologists with the connection to the educational process of endocrinologists, nutritionists, gastroenterologists, pediatricians.

For successful recovery, it is important not only to remove the calculus from the urinary tract, but also to prevent the recurrence of stone formation, the appointment of appropriate therapy aimed at correcting metabolic disorders for each particular patient.

The least invasive stone removal technologies, widely implemented in medical practice, made one of the stages of therapy relatively safe and routine.

Prevention

Urolithiasis is prevented with the help of pharmacological and dietary correction. An increase in diuresis to 2.5-3 l due to the expansion of drinking regimen is recommended for all types of disease. With urate, calcium and oxalate lithiasis, an increase in the intake of potassium and citrates is shown. Citrate, alkalinizing urine, increase the solubility of urates, and also bind calcium in the digestive tract, thereby reducing the recurrence of calcium nephrolithiasis. It is necessary to limit the diet of animal protein and salt, as well as products containing substances involved in calculus formation. So, with uratnogo lithiasis, meat, purine-rich foods, alcohol, with oxaluria - sorrel, spinach, rhubarb, beans, capsicum, lettuce, chocolate are excluded.

Substitution of animal proteins with plant (soybean) enhances calcium binding in the gastrointestinal tract and reduces its concentration in the urine, while calcium nephrolithiasis should not sharply limit calcium intake: a low calcium diet increases calcium absorption in the digestive tract, increases oxaluria and can induce osteoporosis. To reduce hypercalciuria, thiazides are used (hydrochlorothiazide 50-100 mg / day monthly and courses 5-6 times a year) under the control of uric acid, calcium and potassium levels of blood. With pronounced hyperuricosuria prescribe allopurinol. The use of allopurinol is effective for the prevention of oxalate-calcium nephrolithiasis.

[68], [69], [70], [71], [72], [73], [74],