泌尿系损伤泌尿系损伤泌尿系损伤泌尿系损伤Urologic TraumaUrologic TraumaUrologic TraumaUrologic Trauma陈陈 斌斌 上海第二医科大学附属仁济医院上海第二医科大学附属仁济医院 泌尿外科泌尿外科泌尿系损伤特点泌尿系损伤特点泌尿系损伤特点泌尿系损伤特点多合并有其他脏器损伤多合并有其他脏器损伤 肾脏：肾周组织、肋骨保护肾脏：肾周组织、肋骨保护 暴力有关暴力有关 输尿管：输尿管： 位置深位置深 最少见最少见 多为多为医源性医源性 膀胱：盆腔内膀胱：盆腔内 充盈时易损伤充盈时易损伤 尿道：骨盆骨折时尿道：骨盆骨折时 最多见最多见泌尿系损伤主要表现：泌尿系损伤主要表现：出血及尿外渗出血及尿外渗急症诊断和处理急症诊断和处理急症诊断和处理急症诊断和处理特殊检查特殊检查1. 1. 导尿以及损伤评估导尿以及损伤评估1 1）导尿术）导尿术 后尿道损伤需谨慎！后尿道损伤需谨慎！2 2）排泄性尿路造影）排泄性尿路造影3 3）逆行膀胱造影）逆行膀胱造影急症诊断和处理急症诊断和处理急症诊断和处理急症诊断和处理特殊检查特殊检查4 4）输尿管造影）输尿管造影5 5）动脉造影）动脉造影6 6）CTCT2.2.膀胱镜和逆行尿路造影膀胱镜和逆行尿路造影肾损伤肾损伤肾损伤肾损伤 (renal trauma)(renal trauma)(renal trauma)(renal trauma)病因病因开放性：刀枪伤开放性：刀枪伤闭合性：撞击伤闭合性：撞击伤 最多见最多见自发性：肾本身疾病自发性：肾本身疾病医源性：医疗操作医源性：医疗操作损伤病理类型损伤病理类型1.1.肾挫伤肾挫伤 不需手术可自愈不需手术可自愈2.2.肾部分裂伤肾部分裂伤 一般不需手术可自愈一般不需手术可自愈3.3.肾全层裂伤肾全层裂伤 一般需手术一般需手术4.4.肾蒂损伤肾蒂损伤 迅速确诊进行手术迅速确诊进行手术肾损伤肾损伤肾损伤肾损伤 (renal trauma)(renal trauma)(renal trauma)(renal trauma)肾损伤肾损伤肾损伤肾损伤 (renal trauma)(renal trauma)(renal trauma)(renal trauma)临床表现临床表现（与损伤程度有关）（与损伤程度有关）1.1.1.休克休克休克：多发生于严重肾裂伤、肾蒂损伤多发生于严重肾裂伤、肾蒂损伤2.2.2.血尿血尿血尿：多见肉眼血尿，与损伤程度不一致多见肉眼血尿，与损伤程度不一致3.3.3.疼痛疼痛疼痛: : : 多发生多发生 腹痛腹痛 腹膜刺激征腹膜刺激征 肾绞痛肾绞痛4.4.4.腰腹部肿块腰腹部肿块腰腹部肿块：出血多出血多 尿外渗，可有皮下瘀斑尿外渗，可有皮下瘀斑5.5.发热发热：损伤损伤8 8小时以上小时以上 继发感染继发感染肾损伤肾损伤肾损伤肾损伤 (renal trauma)(renal trauma)(renal trauma)(renal trauma)诊断诊断1.1.病史及临床表现：病史及临床表现： 腰部外伤史腰部外伤史 。 症状与肾损伤的严重程度症状与肾损伤的严重程度不成正比不成正比2.2.化验：尿中含多量红细胞化验：尿中含多量红细胞肾损伤肾损伤肾损伤肾损伤 (renal trauma)(renal trauma)(renal trauma)(renal trauma) 诊断诊断3.3.特殊检查：特殊检查： B B超超 方便快捷方便快捷 CT CT 首选首选 排泄性尿路造影排泄性尿路造影 可评价对侧肾功能可评价对侧肾功能 MRI MRI 显示血肿较显示血肿较CTCT有特征性有特征性 肾动脉造影肾动脉造影 少用少用 逆行肾盂造影：易感染不宜用逆行肾盂造影：易感染不宜用逆行肾盂造影：易感染不宜用肾损伤肾损伤肾损伤肾损伤 (renal trauma) (renal trauma) (renal trauma) (renal trauma) 治疗治疗原则：多数可保守治疗，少数手术治疗原则：多数可保守治疗，少数手术治疗原则：多数可保守治疗，少数手术治疗原则：多数可保守治疗，少数手术治疗紧急治疗：紧急治疗： 抗休克抗休克 补充容量，维持水电介质平衡补充容量，维持水电介质平衡 查明有否复合损伤查明有否复合损伤 手术探查准备手术探查准备肾损伤肾损伤肾损伤肾损伤 (renal trauma) (renal trauma) (renal trauma) (renal trauma) 治疗治疗保守治疗：保守治疗：绝对卧床绝对卧床2 2 4 4周周 休息休息2 2 3 3月月密切观察生命体征密切观察生命体征 尿色变化尿色变化预防感染预防感染 广谱抗生素广谱抗生素镇静、止痛、止血治疗镇静、止痛、止血治疗支持治疗支持治疗肾损伤肾损伤肾损伤肾损伤 (renal trauma) (renal trauma) (renal trauma) (renal trauma) 治疗治疗手术治疗：手术治疗：所有开放性肾损伤所有开放性肾损伤确诊为严重肾裂伤、肾碎裂、肾蒂损伤确诊为严重肾裂伤、肾碎裂、肾蒂损伤保守治疗期间发生：保守治疗期间发生：抗休克无效抗休克无效血尿加重血尿加重腰腹肿块增大腰腹肿块增大有腹腔脏器损伤可能有腹腔脏器损伤可能肾损伤肾损伤肾损伤肾损伤 (renal trauma) (renal trauma) (renal trauma) (renal trauma) 治疗治疗只有在肾严重碎裂或肾血管撕裂，无法修补，只有在肾严重碎裂或肾血管撕裂，无法修补，而对侧肾功能良好时，才行肾切除！而对侧肾功能良好时，才行肾切除！并发症及治疗：常由血肿或尿外渗引起并发症及治疗：常由血肿或尿外渗引起尿液囊肿、肾脓肿：切开引流尿液囊肿、肾脓肿：切开引流 输尿管狭窄：输尿管狭窄： 输尿管成形术输尿管成形术 恶性高血压：恶性高血压： 肾血管扩张或修复术肾血管扩张或修复术 持续性血尿：持续性血尿： 肾动脉造影及栓塞术肾动脉造影及栓塞术尿道损伤尿道损伤尿道损伤尿道损伤(urethral injuries)(urethral injuries) 特点：特点：泌尿系损伤中最多见、男性多见泌尿系损伤中最多见、男性多见前尿道损伤（阴茎部和球部损伤）：前尿道损伤（阴茎部和球部损伤）：骑跨伤骑跨伤多见多见后尿道损伤（膜部和前列腺部损伤）：骨盆骨折后尿道损伤（膜部和前列腺部损伤）：骨盆骨折尿道内损伤：医源性多见尿道内损伤：医源性多见前尿道损伤前尿道损伤前尿道损伤前尿道损伤 临床表现临床表现 ：尿道出血尿道出血局部血肿及瘀斑局部血肿及瘀斑疼痛疼痛排尿困难排尿困难尿外渗尿外渗 （p823p823）：）： 球部尿道：阴囊球部尿道：阴囊 会阴、阴茎会阴、阴茎 腹壁腹壁尿道阴茎部：阴茎尿道阴茎部：阴茎前尿道损伤前尿道损伤前尿道损伤前尿道损伤诊断要点诊断要点： 1. 1. 骑跨伤病史骑跨伤病史 2. 2. 典型的血肿和尿外渗分布典型的血肿和尿外渗分布 3. 3. 试插导尿管试插导尿管 4. 4. 尿道造影尿道造影前尿道损伤前尿道损伤前尿道损伤前尿道损伤治疗原则治疗原则： 1. 1. 抗休克抗休克 2. 2. 抗感染抗感染 3. 3. 导尿成功则留置导尿成功则留置2-32-3周周 4. 4. 尿道完全断裂插管失败则端端吻合术尿道完全断裂插管失败则端端吻合术 或膀胱耻骨上造瘘术或膀胱耻骨上造瘘术 5. 5. 并发症处理：尿外渗引流、尿道扩张并发症处理：尿外渗引流、尿道扩张后尿道损伤后尿道损伤后尿道损伤后尿道损伤临床表现：临床表现： 休克（多为骨盆骨折引起）休克（多为骨盆骨折引起）休克（多为骨盆骨折引起） 血尿及尿道出血血尿及尿道出血血尿及尿道出血 下腹部疼痛下腹部疼痛下腹部疼痛 排尿困难（急性尿潴留）排尿困难（急性尿潴留）排尿困难（急性尿潴留） 尿外渗尿外渗尿外渗及血肿及血肿及血肿 （p825p825p825）尿生殖膈完整：耻骨后间隙及膀胱周围尿生殖膈完整：耻骨后间隙及膀胱周围尿生殖膈断裂：会阴、阴囊尿生殖膈断裂：会阴、阴囊后尿道损伤后尿道损伤后尿道损伤后尿道损伤诊断要点诊断要点： 1. 1. 骨盆骨折史，常伴休克骨盆骨折史，常伴休克 2. 2. 排尿困难，尿潴留排尿困难，尿潴留 3. 3. 直肠指检：前列腺尖浮动及柔直肠指检：前列腺尖浮动及柔 软血肿指套染血提示直肠破裂软血肿指套染血提示直肠破裂 4. X4. X片示骨盆骨折片示骨盆骨折后尿道损伤后尿道损伤后尿道损伤后尿道损伤治疗原则治疗原则： 1.1.1.抗休克治疗抗休克治疗抗休克治疗 2.2.2.病人情况允许则行尿道会师术否则膀胱造瘘术病人情况允许则行尿道会师术否则膀胱造瘘术病人情况允许则行尿道会师术否则膀胱造瘘术 3. 3. 3.后期并发尿道狭窄则行尿道扩张或端端吻合术后期并发尿道狭窄则行尿道扩张或端端吻合术后期并发尿道狭窄则行尿道扩张或端端吻合术 4. 4. 4.合并直肠损伤，早期修补并暂时结肠造瘘合并直肠损伤，早期修补并暂时结肠造瘘合并直肠损伤，早期修补并暂时结肠造瘘 膀胱、尿道损伤膀胱、尿道损伤膀胱、尿道损伤膀胱、尿道损伤鉴别鉴别 腹膜外膀胱破裂腹膜外膀胱破裂腹膜外膀胱破裂 后尿道损伤后尿道损伤后尿道损伤 前尿道损伤前尿道损伤前尿道损伤病因病因病因 骨盆骨折骨盆骨折骨盆骨折 骨盆骨折骨盆骨折骨盆骨折 骑跨伤骑跨伤骑跨伤膀胱情况膀胱情况膀胱情况 空虚空虚空虚 充盈充盈充盈 充盈充盈充盈尿外渗范围尿外渗范围尿外渗范围 耻骨后间隙耻骨后间隙耻骨后间隙 耻骨后间隙耻骨后间隙耻骨后间隙 会阴浅袋会阴浅袋会阴浅袋试插导尿管试插导尿管试插导尿管 顺利顺利顺利 后尿道受阻后尿道受阻后尿道受阻 前尿道受阻前尿道受阻前尿道受阻 膀胱注水试验膀胱注水试验膀胱注水试验 少或无少或无少或无 等或更多等或更多等或更多 等或更多等或更多等或更多 直肠指检直肠指检直肠指检 前壁压痛前壁压痛前壁压痛 前壁压痛前壁压痛前壁压痛 正常正常正常前列腺位置前列腺位置前列腺位置 正常正常正常 上升上升上升 正常正常正常XX X线造影线造影线造影 膀胱处外溢膀胱处外溢膀胱处外溢 断裂处外溢断裂处外溢断裂处外溢 断裂处外溢断裂处外溢断裂处外溢尿尿尿尿 石石石石 症症症症UrolithiasisUrolithiasis陈陈 斌斌 仁济医院仁济医院 泌尿外科泌尿外科概概概概 述述述述有史以来折磨人类最久的疾病之一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，男女比约最常见的泌尿科疾病之一，男女比约3 3：1 1人们对于该病治疗方法的进展远超越对人们对于该病治疗方法的进展远超越对于病因的了解于病因的了解90%90%尿路结石不再采用传统的开放手术尿路结石不再采用传统的开放手术发病有地区性，江南多于江北发病有地区性，江南多于江北概概概概 况况况况形成机制未完全阐明，有多种学说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近年来，肾、输尿管上尿路结石发病率明显提高明显提高如果没有随访及医学干预，尿石症如果没有随访及医学干预，尿石症5 5年内年内的复发率高达的复发率高达50%50%Components of stonesComponents of stones晶体晶体+ +基质基质( (crystalcrystal + + matrixmatrix) ) 草酸钙、磷酸钙、磷酸镁铵、尿酸、胱氨酸草酸钙、磷酸钙、磷酸镁铵、尿酸、胱氨酸上尿路（肾、输尿管）结石多为上尿路（肾、输尿管）结石多为草酸钙草酸钙结石、结石、草酸钙草酸钙与与磷酸钙磷酸钙混合性结石混合性结石下尿路结石下尿路结石磷酸镁铵、尿酸铵磷酸镁铵、尿酸铵结石多见结石多见尿石成分及其性质尿石成分及其性质尿石成分及其性质尿石成分及其性质成成 分分质地质地表表 面面色泽色泽原因原因透光否透光否草酸钙草酸钙硬硬粗糙、不规则粗糙、不规则 棕褐色棕褐色基因基因不透光不透光磷酸钙磷酸钙磷酸镁铵磷酸镁铵易碎易碎粗糙、不规则粗糙、不规则鹿角状结石鹿角状结石黄色、灰黄色、灰白、棕色白、棕色梗阻梗阻感染感染X X片上片上分层分层尿酸尿酸硬硬光滑、不规则光滑、不规则 黄、棕红黄、棕红痛风痛风透光透光胱氨酸胱氨酸韧韧光滑蜡样外观光滑蜡样外观 黄棕淡黄黄棕淡黄遗传遗传半透光半透光Etiology AspectsExtrinsic FactorsExtrinsic FactorsIntrinsic FactorsIntrinsic FactorsHeredityHeredityAge and SexAge and SexAbnormal Abnormal metabolymetabolyLocal factorsLocal factorsExtrinsic FactorsExtrinsic FactorsClimatic and seasonal factorsClimatic and seasonal factorsWater intakeWater intakeDietDietMedicationMedicationWater intakeWater intakethe the volume volume of water ingested as opposed to of water ingested as opposed to that lost by perspiration and respirationthat lost by perspiration and respirationthe the mineral or trace elementmineral or trace element content of the content of the water supply of the regionwater supply of the regionDietDietProteinProteinIncreasing the acid in urine Increasing the acid in urine HyperuricosuriaHyperuricosuriaCalciumCalcium HypercalciuriaHypercalciuria HyperoxaluriaHyperoxaluriaDietDietSodiumSodiumHypercalciuriaHypercalciuria MagnesiumMagnesiumInhibit crystallization of Calcium Inhibit crystallization of Calcium PhosphatePhosphatereduce calcium oxalate reduce calcium oxalate crystalloiduriacrystalloiduriaVitaminsVitaminsMedicationsMedicationsSteroidsSteroidsVitaminsVitaminsSulfanilamideSulfanilamideAbnormal Abnormal metabolymetabolyCalcium Calcium O Oxalate xalate S StonetoneCalcium Phosphate StoneCalcium Phosphate StoneUric Acid StoneUric Acid StoneCystine StoneCystine StoneLocal FactorsLocal FactorsUrinary InfectionUrinary InfectionUrinary ObstructionUrinary ObstructionUrinary Urinary EyewinkerEyewinkerLocal FactorsLocal FactorsUrinary Tract InfectionUrinary Tract Infection 产生解产生解脲酶脲酶的细菌的细菌- -变形杆菌感染变形杆菌感染尿液中基质增加，促进晶体粘附尿液中基质增加，促进晶体粘附感染性结石感染性结石（磷酸镁铵）形成的条件（磷酸镁铵）形成的条件pH7.2pH7.2尿中有氨存在尿中有氨存在Local FactorsLocal FactorsUrinary Obstruction &Urinary Obstruction & Anatomic Abnormalities Anatomic Abnormalities近端扩张、尿滞留，尿液浓缩，成石物近端扩张、尿滞留，尿液浓缩，成石物质过饱和质过饱和结石近端产生涡流，成石物质沉淀结石近端产生涡流，成石物质沉淀梗阻部位妨碍微石排出梗阻部位妨碍微石排出尿液滞留继发尿路感染尿液滞留继发尿路感染Local FactorsLocal FactorsUrinary Tract Urinary Tract EyewinkerEyewinker 可作为可作为核心核心诱发成石物质沉淀和附着诱发成石物质沉淀和附着各种导管、内支架各种导管、内支架手术时遗留的丝线手术时遗留的丝线人为塞入膀胱的金属、木条、塑料人为塞入膀胱的金属、木条、塑料成成成成 石石石石 机机机机 制制制制PathogenesisPathogenesisProcessProcess Nucleation (Nucleation (晶核形成晶核形成) ) Crystal Growth ( Crystal Growth (结晶生长结晶生长) ) Crystal Aggregation ( Crystal Aggregation (结晶聚集结晶聚集) ) Crystal Retention ( Crystal Retention (结晶滞留结晶滞留) )病病病病 理理理理 生生生生 理理理理 * *PathophysiologyPathophysiologyPathophysiologyPathophysiology肾和膀胱内形成结石肾和膀胱内形成结石与结石部位、大小、数目、继发炎症、与结石部位、大小、数目、继发炎症、梗阻程度等有关梗阻程度等有关结石排出过程中，可停留在输尿管和尿结石排出过程中，可停留在输尿管和尿道，形成该处结石道，形成该处结石PathophysiologyPathophysiology肾盏结石阻塞肾盂输尿管连接处或输尿管肾盏结石阻塞肾盂输尿管连接处或输尿管急性完全性急性完全性梗阻梗阻解除梗阻，可无肾损害解除梗阻，可无肾损害慢性不完全性梗阻慢性不完全性梗阻导致肾积水，影响肾功能导致肾积水，影响肾功能较大肾盂结石对肾实质和肾功能损害轻微较大肾盂结石对肾实质和肾功能损害轻微PathophysiologyPathophysiology输尿管内径自上而下由粗变细输尿管内径自上而下由粗变细- -输尿管下输尿管下1/31/3处结石最多见处结石最多见进入输尿管，常停留嵌顿于生理狭窄处进入输尿管，常停留嵌顿于生理狭窄处 肾盂输尿管连接处肾盂输尿管连接处 输尿管跨越髂血管处输尿管跨越髂血管处 输尿管膀胱连接处输尿管膀胱连接处PathophysiologyPathophysiology结石结石损伤损伤尿路粘膜导致出血、尿路粘膜导致出血、感染感染梗阻梗阻易发生感染易发生感染感染、梗阻可促使结石形成及长大感染、梗阻可促使结石形成及长大肾盂及膀胱内结石可引起肾盂及膀胱内结石可引起恶变恶变充满肾盂、部分或全部肾盏：充满肾盂、部分或全部肾盏：鹿角形结石鹿角形结石 ( (StaghornStaghorn) )SuspenseSuspense If urinary constituents are similar from each kidney If urinary constituents are similar from each kidney and if there is no evidence of obstruction,and if there is no evidence of obstruction,Why do most stones present in a unilateral Why do most stones present in a unilateral fashion?fashion?Why dont small stones pass uneventfully Why dont small stones pass uneventfully down the ureter early in their development?down the ureter early in their development?Why do some people form one large stone Why do some people form one large stone and others form multiple small calculi?and others form multiple small calculi?上尿路结石上尿路结石Upper Urinary Tract CalculiUpper Urinary Tract CalculiTypes of StonesTypes of Stonescalcium saltscalcium saltsstruvitestruvite (infection stones) (infection stones)uric aciduric acidcystinecystine(infection (infection stones)stones)Made of crystallized magnesium and Made of crystallized magnesium and ammonia phosphateammonia phosphateClinical Presentation*Clinical Presentation*PainPain & & HematuriaHematuria associated with activity associated with activityThe character of the pain depends on the stone The character of the pain depends on the stone location, size, movement and complicationlocation, size, movement and complicationRenal ColicRenal Colic and and noncolickynoncolicky renal pain are two renal pain are two types of pain originating from kidneytypes of pain originating from kidneyNoncolickyNoncolicky renal pain is caused by distention renal pain is caused by distention of the renal capsuleof the renal capsuleSymptoms & SignsSymptoms & SignsRenal ColicRenal Colic ( (肾绞痛肾绞痛) usually is caused ) usually is caused by stretching of the collecting system or by stretching of the collecting system or ureterureterUrinary obstruction is the main Urinary obstruction is the main mechanism responsible for renal colicmechanism responsible for renal colicLocal mechanism such as Local mechanism such as inflammation, edema, inflammation, edema, hyperperistalsishyperperistalsis may contribute to the perception of may contribute to the perception of painpainRenal (Ureteral) ColicRenal (Ureteral) Colic肾绞痛肾绞痛Comes on suddenly and acutelyComes on suddenly and acutelyWax and Wane, may be relatively constantWax and Wane, may be relatively constantUsually starts in the back, at waist or in Usually starts in the back, at waist or in the flank, stomach or grointhe flank, stomach or groinNausea, vomiting, chills, feverNausea, vomiting, chills, feverFrequently move constantly into unusual Frequently move constantly into unusual position in an attempt to relieve the painposition in an attempt to relieve the painRenal (Ureteral) ColicRenal (Ureteral) ColicRadiation of pain Radiation of pain ：PUJPUJ or upper ureteral tract obstructionor upper ureteral tract obstruction 腰部及上腹部，并沿输尿管行经放射至同侧腰部及上腹部，并沿输尿管行经放射至同侧睾丸、阴唇和大腿内侧睾丸、阴唇和大腿内侧MidureteralMidureteral obstruction obstruction 中下腹，易与急性阑尾炎混淆中下腹，易与急性阑尾炎混淆Distal ureter entering vesical, ureteral orificeDistal ureter entering vesical, ureteral orifice 伴膀胱刺激症状，尿道伴膀胱刺激症状，尿道/ /阴茎头放射痛阴茎头放射痛HematuriaHematuriaBlood in the urine - another classic symptomBlood in the urine - another classic symptomThe blood may be clearly visible, or may be The blood may be clearly visible, or may be microhematuriamicrohematuriaOften, patients urine is usually tea-colored Often, patients urine is usually tea-colored and/or cloudyand/or cloudyMicrohematuria after movement may be the Microhematuria after movement may be the only one symptomonly one symptom Symptoms & SignsSymptoms & Signs无尿无尿 ( (anuriaanuria) )双侧上尿路结石引起双侧完全性梗阻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独肾上尿路结石完全性梗阻结石伴感染：结石伴感染：frequencyfrequency、dysuriadysuria继发急性肾盂肾炎或肾积脓继发急性肾盂肾炎或肾积脓畏寒、寒战等全身症状畏寒、寒战等全身症状有时感染症状可以是尿路结石唯一表现有时感染症状可以是尿路结石唯一表现DiagnosisDiagnosisHistoryHistoryEvaluate the Evaluate the nature of the painnature of the pain, including , including its its onset;onset; character; potential radiation; character; potential radiation; activities that exacerbate or ease the painactivities that exacerbate or ease the painAssociate nausea, vomitingAssociate nausea, vomitingGross hematuriaGross hematuriaHistory of similar painHistory of similar painHistoryHistoryTypical renal, ureteral colic with hematuriaTypical renal, ureteral colic with hematuriaRisk factorsRisk factorsCrystalluriaCrystalluriaDietDietOccupation and climateOccupation and climateFamily historyFamily historyMedicationsMedicationsPhysical ExaminationPhysical ExaminationAttempting to find relief in multiple, Attempting to find relief in multiple, frequently, bizarre frequently, bizarre positionspositionsTachycardia, sweating and nauseaTachycardia, sweating and nauseaAn An abdominal massabdominal mass may be palpable in may be palpable in patients with long-standing obstructive patients with long-standing obstructive urinary calculi & severe hydronephrosisurinary calculi & severe hydronephrosisPhysical ExaminationPhysical ExaminationAbdominal Examination should exclude Abdominal Examination should exclude other other causes of abdominal paincauses of abdominal painExamination of abdomen reveals Examination of abdomen reveals moderate deep tenderness on moderate deep tenderness on palpation palpation over the location of the calculus and the over the location of the calculus and the area of the loinarea of the loinDiagnosisDiagnosisStone diagnosisStone diagnosis including location, size, number, shape, type including location, size, number, shape, typeComplication diagnosisComplication diagnosisUrinary infectionUrinary infectionDegree of obstructionDegree of obstructionRenal failureRenal failure EEtiologicaltiological evaluation evaluationLaboratory TestLaboratory TestUrinalysis (Urinalysis (尿液分析尿液分析) )Microscopic or gross hematuriaMicroscopic or gross hematuriaModerate pyuria or pus cellsModerate pyuria or pus cellsGross hematuria may be the only complaintGross hematuria may be the only complaintCrystalluriaCrystalluriaUrine germiculture (Urine germiculture (尿细菌培养尿细菌培养) )Laboratory TestLaboratory TestSerum biochemistry examinationSerum biochemistry examinationCa, P, Cr, AKP, Uric acid, Albumen, K, Na, Ca, P, Cr, AKP, Uric acid, Albumen, K, Na, ClCl, , PTH, etcPTH, etcAnalysis of urinary metabolites in 24-hour Analysis of urinary metabolites in 24-hour urine collectionsurine collectionsAcidified sample - Calcium, Oxalate, Acidified sample - Calcium, Oxalate, Magnesium, PhosphorusMagnesium, PhosphorusAlkaline sample Uric acidAlkaline sample Uric acidUntreated aliquots - CreatinineUntreated aliquots - CreatinineLaboratory TestLaboratory TestAnalysis of Analysis of UrolithsUrolithsChemical analysis Chemical analysis qualitative & qualitative & semiquantitativesemiquantitativeInfrared SpectroscopyInfrared SpectroscopyBinocular Stereoscopic microscopeBinocular Stereoscopic microscopeX-ray Diffraction, Electron MicroscopyX-ray Diffraction, Electron MicroscopyA combination of morphologic and structural A combination of morphologic and structural examination of stone has shown to provide a examination of stone has shown to provide a cost-effective, precise, and reliable analysis of cost-effective, precise, and reliable analysis of stonestoneDiagnostic Diagnostic UroradiologyUroradiologyUltrasonography (Type B)Ultrasonography (Type B)Noninvasive method for screening urinary Noninvasive method for screening urinary stonestoneSensitive in detecting radiolucent calculi Sensitive in detecting radiolucent calculi particularly those measuring 23mm in particularly those measuring 23mm in largest dimension small stones largest dimension small stones Diagnostic Diagnostic UroradiologyUroradiologyUltrasonography (Type B)Ultrasonography (Type B)Presenting anatomic structure changes Presenting anatomic structure changes and hydronephrosisand hydronephrosisAn An echogenicechogenic focus with posterior focus with posterior acoustic shadowingacoustic shadowingFalse-positiveFalse-positiveRadiographic ExaminationRadiographic Examination泌尿系平片泌尿系平片95%95%以上结石可显示以上结石可显示结石过小或钙化程度不高者可不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纯尿酸结石及基质结石可不显示如结石厚度小于如结石厚度小于2mm2mm则无法分辨则无法分辨是诊断输尿管结石的最基本方法是诊断输尿管结石的最基本方法区分淋巴钙化、静脉石、骨岛区分淋巴钙化、静脉石、骨岛Radiographic ExaminationRadiographic Examination排泄性尿路造影排泄性尿路造影 （IVU / IVPIVU / IVP）可确诊肾结石可确诊肾结石肾结构与功能改变肾结构与功能改变透光结石可显示充盈缺损透光结石可显示充盈缺损绞痛发作后绞痛发作后2 2周再做周再做Radiographic ExaminationRadiographic ExaminationComputerized Tomography (CT)Computerized Tomography (CT)可分辨可分辨0.5mm0.5mm结石结石可显示任何成分的结石可显示任何成分的结石螺旋螺旋CTCT可检出可检出90%90%输尿管结石输尿管结石输尿管结石表现为高密度影及输尿管结石表现为高密度影及“ “框边框边” ”逆行肾盂造影：其他方法不能确定时逆行肾盂造影：其他方法不能确定时输输输输 尿尿尿尿 管管管管 肾肾肾肾 镜镜镜镜可明确诊断并可治疗可明确诊断并可治疗检查指征检查指征腹部平片未显示结石腹部平片未显示结石排泄性尿路造影有充盈缺损排泄性尿路造影有充盈缺损Differential DiagnosisDifferential DiagnosisAcute abdomen ( Acute abdomen ( peritoneal signsperitoneal signs! ! ) )Acute appendicitisAcute appendicitisEctopic and unrecognized pregnanciesEctopic and unrecognized pregnanciesOvarian pathologic conditionsOvarian pathologic conditionsBiliary stones with & without obstructionBiliary stones with & without obstructionPeptic ulcer diseasePeptic ulcer diseaseAcute renal artery embolism, etcAcute renal artery embolism, etcDifferential DiagnosisDifferential Diagnosis *有感染时有感染时是感染导致结石抑或结石继发感染？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、静脉石胆囊结石、肠系膜淋巴结钙化、静脉石正、侧位摄片正、侧位摄片侧位片上尿路结石位于椎体前缘之后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输尿管平片双曝光斜位摄片治治治治 疗疗疗疗有无确定病因有无确定病因有无代谢异常有无代谢异常有无梗阻和感染及其程度有无梗阻和感染及其程度结石大小、部位、数目、肾功能和全身结石大小、部位、数目、肾功能和全身情况情况保保保保 守守守守 治治治治 疗疗疗疗结石小于结石小于0.60.6厘米厘米直径小于直径小于0.40.4厘米光滑结石厘米光滑结石90%90%可自行排出可自行排出结石表面光滑结石表面光滑无尿路梗阻，无感染无尿路梗阻，无感染纯尿酸结石或纯胱氨酸结石纯尿酸结石或纯胱氨酸结石有排石史者有排石史者保保保保 守守守守 治治治治 疗疗疗疗注意观察每次排出尿液，有无结石排出注意观察每次排出尿液，有无结石排出大量饮水大量饮水是预防结石形成和长大最有效的方法是预防结石形成和长大最有效的方法每天保持每天保持20002000毫升以上毫升以上睡前及半夜饮水，保持夜间尿液稀释状态睡前及半夜饮水，保持夜间尿液稀释状态控制感染：抗生素控制感染：抗生素保保保保 守守守守 治治治治 疗疗疗疗饮食调节饮食调节限制含钙、草酸成分丰富的食物限制含钙、草酸成分丰富的食物钙：牛奶、奶制品、豆制品、巧克力、坚果钙：牛奶、奶制品、豆制品、巧克力、坚果草酸：浓茶、番茄、菠菜、芦笋草酸：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、鱼虾尿酸结石忌高嘌呤食物：动物内脏、鱼虾保保保保 守守守守 治治治治 疗疗疗疗调节尿液调节尿液pHpH值值碱化尿液：枸橼酸钾、重碳酸钠碱化尿液：枸橼酸钾、重碳酸钠可预防、治疗胱氨酸结石可预防、治疗胱氨酸结石预防：尿液保持预防：尿液保持pHpH在在6.56.5治疗：尿液保持治疗：尿液保持pHpH在在77.577.5酸化尿液：氯化铵酸化尿液：氯化铵防止感染性结石的生长防止感染性结石的生长保保保保 守守守守 治治治治 疗疗疗疗中西医结合综合疗法中西医结合综合疗法对于纯尿酸结石对于纯尿酸结石- -溶石效果最好溶石效果最好大量饮水大量饮水饮食调节饮食调节碱化尿液碱化尿液口服别嘌呤醇口服别嘌呤醇保保保保 守守守守 治治治治 疗疗疗疗感染性结石感染性结石控制感染控制感染取除结石取除结石酸化尿液酸化尿液应用脲酶抑制剂应用脲酶抑制剂 - -乙酰异羟乙酰异羟肟酸肟酸保保保保 守守守守 治治治治 疗疗疗疗胱氨酸结石胱氨酸结石碱化尿液，使碱化尿液，使pHpH大于大于7.87.8D-D-青霉胺，青霉胺， - -巯丙酰甘氨酸（巯丙酰甘氨酸（ - -MPGMPG）、）、乙酰半胱氨酸可用来溶石乙酰半胱氨酸可用来溶石卡托普利可用来预防卡托普利可用来预防肾绞痛：解痉、镇静、镇痛肾绞痛：解痉、镇静、镇痛体外冲击波碎石体外冲击波碎石体外冲击波碎石体外冲击波碎石EExtracorporeal xtracorporeal SShock hock WWave ave LLithotripsyithotripsy多数上尿路结石适用多数上尿路结石适用- -首选方法首选方法XX线、线、BB超定位，冲击波聚焦后作用于结石超定位，冲击波聚焦后作用于结石适宜于适宜于0.52.5cm0.52.5cm的结石的结石碎石效果与结石部位、大小、性质、是否碎石效果与结石部位、大小、性质、是否嵌顿等因素有关嵌顿等因素有关击碎结石堆积于输尿管内击碎结石堆积于输尿管内- -石街石街再次碎石，间隔时间不少于再次碎石，间隔时间不少于7 7天天体外冲击波碎石体外冲击波碎石体外冲击波碎石体外冲击波碎石禁忌症：禁忌症：妊娠妊娠 绝对禁忌绝对禁忌结石远端尿路梗阻结石远端尿路梗阻出血性疾病出血性疾病严重心脑血管病严重心脑血管病安置心脏起搏器患者安置心脏起搏器患者血肌酐血肌酐265265 mol/Lmol/L、急性尿路感染急性尿路感染育龄妇女下段输尿管结石育龄妇女下段输尿管结石手手手手 术术术术 治治治治 疗疗疗疗分为开放手术及非开放手术两类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手术前必须了解双侧肾功能有感染时应先抗感染治疗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输尿管结石手术，入手术室前需再做腹部平片，做最后定位平片，做最后定位有原发梗阻因素存在时，应同时予以纠正有原发梗阻因素存在时，应同时予以纠正非非非非 开开开开 放放放放 手手手手 术术术术输尿管肾镜取石或碎石术输尿管肾镜取石或碎石术适用于中、下段输尿管结石适用于中、下段输尿管结石平片不显影结石平片不显影结石因肥胖、结石硬、停留时间长而不能用因肥胖、结石硬、停留时间长而不能用ESWLESWLESWLESWL所致之所致之“ “石街石街” ”主要并发症：出血、感染、穿孔主要并发症：出血、感染、穿孔经皮肾镜取石或碎石术经皮肾镜取石或碎石术 （PCNLPCNL）开开开开 放放放放 性性性性 手手手手 术术术术指征指征经经ESWLESWL和腔内碎石失败者和腔内碎石失败者结石远端有狭窄、梗阻结石远端有狭窄、梗阻体积多大的复杂性肾结石体积多大的复杂性肾结石结石导致肾功能丧失，被迫行肾切除结石导致肾功能丧失，被迫行肾切除开开开开 放放放放 性性性性 手手手手 术术术术输尿管切开取石术输尿管切开取石术肾盂切开取石术肾盂切开取石术肾窦肾盂切开取石术肾窦肾盂切开取石术肾实质切开取石术肾实质切开取石术无萎缩性肾切开取石术无萎缩性肾切开取石术肾部分切除、肾切除肾部分切除、肾切除凝块法肾盂切开取石术凝块法肾盂切开取石术双侧上尿路结石手术原则双侧上尿路结石手术原则双侧上尿路结石手术原则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：先处理输一侧输尿管结石、对侧肾结石：先处理输尿管结石尿管结石双侧肾结石：根据结石情况及肾功能决定双侧肾结石：根据结石情况及肾功能决定原则上尽可能保留肾原则上尽可能保留肾一般先处理易于取出和安全侧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手术原则双侧上尿路结石手术原则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管或行经皮肾造瘘上尿路结石的预防上尿路结石的预防PreventionPrevention上尿路结石的预防上尿路结石的预防上尿路结石的预防上尿路结石的预防一般性预防方法一般性预防方法大量饮水大量饮水根据结石成分调节饮食根据结石成分调节饮食特殊性预防方法特殊性预防方法草酸盐结石：草酸盐结石：VitB6VitB6、氧化镁氧化镁感染、尿酸、胱氨酸结石：见前述感染、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有甲旁亢者，摘除腺瘤或增生组织膀膀 胱胱 结结 石石尿尿 石石 症症Vesical CalculiVesical Calculi病病病病 因因因因继发性膀胱结石继发性膀胱结石膀胱出口梗阻膀胱出口梗阻膀胱憩室膀胱憩室神经原性膀胱神经原性膀胱异物及长期留置导尿管者异物及长期留置导尿管者肾结石排至膀胱肾结石排至膀胱诊诊诊诊 断断断断临床表现临床表现典型症状：排尿中断，并感疼痛，放射典型症状：排尿中断，并感疼痛，放射至阴茎头部和远端尿道至阴茎头部和远端尿道伴排尿困难和膀胱刺激症伴排尿困难和膀胱刺激症结石位于憩室内可无上述症状，表现为结石位于憩室内可无上述症状，表现为尿路感染尿路感染诊诊诊诊 断断断断XX线检查：平片可显示大多数结石线检查：平片可显示大多数结石BB型超声检查型超声检查 - -高回声伴声影，随体位改变高回声伴声影，随体位改变膀胱镜检查膀胱镜检查- - 最可靠方法最可靠方法直肠指诊能摸到较大的结石直肠指诊能摸到较大的结石治治治治 疗疗疗疗采用手术治疗采用手术治疗经膀胱镜机械、超声、激光等碎石经膀胱镜机械、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骨上膀胱切开取石应同时治疗病因应同时治疗病因膀胱感染严重时，应用抗生素膀胱感染严重时，应用抗生素尿尿 道道 结结 石石Urethral CalculiUrethral CalculiUrolithiasisUrolithiasisConspectusConspectusMajority stones expelled from the kidney & Majority stones expelled from the kidney & bladderbladderRarely may form primarily when stricture, Rarely may form primarily when stricture, pouch or diverticulum presentedpouch or diverticulum presentedUsually only a single stone is encountered in Usually only a single stone is encountered in anterior urethraanterior urethraFemales rarely develop urethral calculiFemales rarely develop urethral calculiDiagnosisDiagnosisClinical PresentingClinical PresentingTypical symptomTypical symptom： Acute urinary retention associated with Acute urinary retention associated with severe perineum/rectum pain severe perineum/rectum pain Pain may radiate to the tip of the penisPain may radiate to the tip of the penisIntermittent urinary streamIntermittent urinary streamTerminal hematuria & infectionTerminal hematuria & infectionDiagnosisDiagnosisConfirmed diagnosis :Confirmed diagnosis : palpation, palpation, endoscopicendoscopic visualization & visualization & radiographic studyradiographic studyA hard mass could be touched via Digital A hard mass could be touched via Digital Rectal Examination in the path of Rectal Examination in the path of urethraurethra治治治治 疗疗疗疗 原原原原 则则则则结石位于尿道舟状窝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，后尿道结石在麻醉下将结石推入膀胱，再按膀胱结石处理再按膀胱结石处理ConclusionConclusionNephrolithiasis is a chronic illness that Nephrolithiasis is a chronic illness that requires an integrated combination of requires an integrated combination of medical and surgical care. medical and surgical care. Medical care is concerned mainly with Medical care is concerned mainly with the recurrent stones, and surgical care the recurrent stones, and surgical care is concerned mainly with the removal is concerned mainly with the removal of existing stones.of existing stones.ConclusionConclusionA small fraction of patients have A small fraction of patients have calcium oxalate stones due to calcium oxalate stones due to specific disorders, such as Primary specific disorders, such as Primary hyperparathyroidism, Renal tubular hyperparathyroidism, Renal tubular acidosis, and Primary or acquired acidosis, and Primary or acquired forms of forms of HyperoxaleuriaHyperoxaleuria. .ConclusionConclusionThe treatment of patients with these The treatment of patients with these disorders or of patients who have disorders or of patients who have uric acid or cystine stone is not uric acid or cystine stone is not controversial and is effective in controversial and is effective in preventing recurrencespreventing recurrences. .In majority of patients (80%), calcium In majority of patients (80%), calcium oxalate stones do not form as a result oxalate stones do not form as a result of specific disease, but rather as result of specific disease, but rather as result of idiopathic of idiopathic hypercalciuriahypercalciuria, , hyperuricosuriahyperuricosuria. As treatments of . As treatments of Idiopathic Idiopathic hypercalciuriahypercalciuria and and hyperuricosuriahyperuricosuria and and allopurinolallopurinol, , respectively, have been found respectively, have been found effective in controlled trials.effective in controlled trials.ConclusionConclusionAlthough Although hydration, dietary hydration, dietary counseling to reduce the oxalate and counseling to reduce the oxalate and calcium intake, and oral citratecalcium intake, and oral citrate have have not been tested adequatelynot been tested adequatelyRecommendation of Consensus conference onRecommendation of Consensus conference on“Prevention and treatment of Kidney Stones” “Prevention and treatment of Kidney Stones” National Institute of Health 1988 National Institute of Health 1988 Virtually all Physician recommend Virtually all Physician recommend hydration to patients in whom hydration to patients in whom stones formstones form