stone disease 3 open surgery of kidney 54. surgical management of upper urinary tract calculi 48...

27
Stone disease 3 Open surgery of kidney 54

Upload: leonard-deming

Post on 28-Mar-2015

217 views

Category:

Documents


3 download

TRANSCRIPT

Page 1: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

Stone disease 3

Open surgery of kidney 54

Page 2: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

Surgical Management of UpperUrinary Tract Calculi 48

Kidney Calculi PelolithotomyNephrolithotomy

•Although stone-free rates of these modern•surgical techniques were excellent, morbidity

was significant,•and the search for new techniques and

technologies•continued.

Page 3: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Ureteral Calculi•Ureterolithotomy•Endourology•Before the development of endoscopy

attempts to blindly extract•calculi were not uncommon.

Page 4: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•The development of minimally invasive surgical techniques forthe treatment of patients suffering from urinary lithiasis has been

greatly dependent on technologic advances in the fields of fiberoptics,

radiographic imaging, and lithotripsy (shockwave,ultrasonic, electrohydraulic, and laser .)

•These advancements have accelerated the evolution of modern techniques

of calculus removal, including ureteroscopy, percutaneousnephrolithotomy (PNL), and extracorporeal

shockwave lithotripsy (SWL).

Page 5: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•term endourology as closed controlled manipulationwithin the genitourinary tract

•Ureteroscopy•Currently available ureteroscopes range from 54 to 70 cm in

length and have a tapered shaft diameter that increases proximally.As the tip of the ureteroscope is inserted into the ureter and

passed retrograde, the ureter is slowly dilated .•Most modern

ureteroscopes have a single working channel, and some have asecond irrigation channel that serves to distend the ureter and

maintain visualization.

Page 6: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Parallel to improvements in rigid and flexible ureteroscopes

were advances in intracorporeal lithotripters, including ultrasonic,

electrohydraulic, pneumatic, and laser probes, allowing

efficient stone fragmentation through the miniaturized modern

ureteroscopic equipment.

Page 7: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Percutaneous Stone Removal•Subsequent advances

in endoscopes, imaging equipment, and intracorporeal lithotripters

allowed urologists and radiologists to refine These percutaneous techniques through the late 1970s

and early 1980sinto well-established methods for removal of upper

urinary tractcalculi.

Page 8: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Extracorporeal Shockwave LithotripsyExamples of high-energy shockwaves include the blast effect associated with explosions, as well as the potentially windowshattering

sonic boom created when aircraft pass beyond the speed of sound .

Engineers at Dornier Medical Systems in what wasthen West Germany, during research on the effects of shockwaves on military hardware, demonstrated that these shockwaves arereflectable and therefore focusable.

•The possibility of applyingshockwave energy to human tissue was discovered when, by

chance, a test engineer touched a target body at the very momentof impact of a high-velocity projectile. The engineer felt a sensation

similar to an electric shock, although the contact point at theskin showed no damage at all

Page 9: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

more than 1 million patients are treated annually with SWL.

RENAL CALCULIThe primary goal of surgical stone management is to achieve maximal stone clearance with minimal morbidity to the

patient .

The introduction of SWL as well as continuingadvancements in the field of endourology have allowed most patients with renal stones to be treated in a minimally invasive fashion.

However, as the armamentarium of treatment modalitiesavailable to the urologist has increased, new controversies regardingthe indications for these therapies have developed. Currently,

urologists face the challenge of selecting the optimal treatmentmodality on the basis of the patient’s and the stone’s characteristics.

Four minimally invasive treatment modalities are availablefor the treatment of patients with kidney stones and are discussedin this chapter: SWL, PNL, ureteroscopy, and laparoscopic stonesurgery.

Page 10: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Most patients harboring “simple” renal calculi can be•treated satisfactorily with SWL.• •However, there are other•patients who are unlikely to achieve a successful outcome with•SWL; factors associated with poor stone clearance rates after SWL•include large renal calculi, stones within dependent or•obstructed portions of the collecting system, stones of•certain composition (cystine, calcium oxalate monohydrate,•and brushite), and obesity or a body habitus that•inhibits imaging and targeting of the stone.

• For patients•with these clinical characteristics, alternative treatment modalities,•such as ureteroscopy or PNL, should be considered. The urologist,•then, when treating a patient with a renal calculus, must ask:•Is the patient an appropriate candidate for SWL, or•should other treatment modalities be used?

Page 11: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Bacteriologic evaluation of the urine is mandatory for all•patients. The composition of any previous stone

material passed•or removed from the patient is extremely important. If

previous•stones have contained significant amounts of calcium

oxalate•monohydrate (whewellite) or brushite, fragmentation

with SWL•may be expected to be more difficult.

Page 12: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•most calyceal stones, in the absence•of intervention, are likely to increase in size

and cause•symptoms of pain or infection.

Page 13: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Staghorn calculi are those stones that fill the major part of the•renal collecting system. Typically, they occupy the renal pelvis and•branch into most of the calyces, mimicking the horns of a deer .

•Most staghorn stones are composed of struvite• .Until the early 1970s some physicians believed•that patients harboring staghorn calculi should not be treated•However, a better understanding of the natural•history of staghorn stones has evolved. It is now generally accepted•that, if left untreated, a staghorn calculus is associated with progressive•deterioration of renal function. Additionally, morbidities•associated with an untreated staghorn stone include pain, recurrent•urinary tract infection, and sepsis events.

Page 14: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•untreated struvite staghorn calculi eventually•destroy the kidney and pose a significant risk

to the•patient’s life.

Page 15: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Stone burden (size and number) is perhaps the single

•most important factor in determining the appropriate

•treatment modality for a patient with renal calculi.

•The negative effect of an increasing stone burden (size

•and number) on the results of SWL has been described

Page 16: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•50% to 60% of all solitary renal calculi are•less than 10 mm in diameter . Treatment results

of SWL•for this substantial group of patients are •generally satisfactory

•Patients with calculi between 10 and 20 mm are often

•treated with SWL as first-line management.

Page 17: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Patients with stones larger than 20 mm•should primarily be treated by PNL unless

specific indications•for ureteroscopy are present (e.g., bleeding

diathesis,•obesity.)

Page 18: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Treatment Decisions by Stone Composition

•patients with such•stones (i.e., brushite, cystine, calcium oxalate

monohydrate)•should be treated by SWL only when the stone•burden is small (i.e., <1.5 cm).

Page 19: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although

•Renal Anatomic Factors•There are certain anatomic factors, either congenital or acquired,•that can hinder stone clearance after SWL. Congenital anomalies•manifest not uncommonly in the upper urinary tract, and almost•all that affect the drainage of the kidney are associated with an

•increased incidence of calculous disease .•Such abnormalities

•include ureteropelvic junction (UPJ) obstruction, horseshoe•kidney, and other ectopic or fusion anomalies as well as calyceal•diverticula. Hydronephrosis, too, is associated with a failure to

•clear stone fragments after SWL.

Page 20: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although
Page 21: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although
Page 22: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although
Page 23: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although
Page 24: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although
Page 25: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although
Page 26: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although
Page 27: Stone disease 3 Open surgery of kidney 54. Surgical Management of Upper Urinary Tract Calculi 48 Kidney Calculi Pelolithotomy Nephrolithotomy Although