Transcript Intervention

Intervention
Interventions
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Conservative observation
Dissolution agents
Relief of Obstruction
Extracorporeal Shockwave Lithotripsy (ESWL)
Ureteroscopic stone extraction
Percutaneous Nephrolithotomy
Open stone surgery
Pyelolithotomy
Anatrophic Nephrolithotomy
Radial Nephrotomy
Ureterolithotomy
others
Conservative management
• Majority of stones pass out within a 6 week period after
the onset of symptoms
• depends on the size of the calculi and its location
Dissolution agents
• Use alkalinizing agents
• Given oral, IV or intrarenal
Relief of the Obstruction
• Emergent drainage in patient with signs of UTI
Extracorporeal Shockwave Lithotripsy (ESWL)
Extracorporeal Shockwave Lithotripsy (ESWL)
Consideration
• excessive weight (>300 lb) may severely
limit or preclude ESWL.
• Pregnant women and patients with large
abdominal aortic aneurysms or
uncorrectable bleeding disorders should
not be treated with ESWL.
• Individuals with cardiac pacemakers
should be thoroughly evaluated by a
cardiologist.
Ureteroscopic stone extraction
• Highly effective
for lower
ureteral calculi
• Stone may be
extracted using
a wire basket
• Or lithotrites
may be placed
through the
ureteroscope to
fragment the
calculi
Percutaneous Nephrolithotomy
• the treatment of choice for large (>2.5 cm)
calculi; renal and proximal ureteral calculi,
those resistant to ESWL, select lower pole
calyceal stones with a narrow, long
infundibulum and an acute infundibulopelvic angle, and instances with evidence
of obstruction
• Rapid cure
Open stone surgery
• Classic way to remove
calculi
• Mandatory to obtain a
radiograph before the
incision is made
• Not frequently used
anymore because of the
morbidity of the incision,
the possibility of retained
stone fragments, and the
ease and success of less
invasive techniques
Pyelolithotomy
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Effective especially with extrarenal
pelvis
Transverse pyelotomy - effective
and does not require interruption
of the renal arterial blood supply
Flexible endoscope – ensures
stone-free status
Coagulum – can retrieve multiple,
small renal pelvic calculi and
difficult- to-access caliceal calculi
Cryoprecipitate
– Injected into the renal pelvis,
endogenous clotting factors result in
a Jelly-like coagulum of the
collecting system.
– Small stones are entrapped and
removed with the coagu- lum.
Anatrophic nephrolithotomy
• Used with complex staghorn calculi
– Complete staghorn calculus
– Partial staghorn calculus
1.Incision made on the convex surface of the
kidney posterior to the line of Brodel
2.Occlusion of the renal artery followed by
renal cooling with slushed ice
3.Nerve hook is helpful to tease out calculi
4.Repair of narrowed infundibula helps reduce
stone recurrence rates.
Radial nephrotomy
• Allows access to limited calyces of the collecting
system
• Frequently used in blown-out calyces with thin
overlying parenchyma
• Intraoperative ultrasound to localize the calyx and
the calculi
• A shallow incision of the renal capsule can be
followed by puncture into the collecting system.
• Stones may be cut with heavy Mayo scissors, and
remaining fragments can be retrieved.
Other renal procedures
• Partial nephrectomy – for large stones in a renal
pole with marked parenchymal thinning
– Caution should be taken even with a normal
contralateral kidney as stones are frequently
associated with a systemic metabolic defect that
may recur in the contralateral kidney
• Ileal ureter substitution – to decrease pain with
frequent stone passage
• Autotransplantation with pyelocystostomy – for
patients with rare malignant stone disease
Partial nephrectomy
Ileal ureter substitution
Ureterolithotomy
• Long standing ureteral calculi
1. Preoperative radiograph to document stone location
2. Incision lateral to the sacrospinalis muscles to allow
medial retraction of the quadratus lumborum;
anterior fascicle of the dorsal lumbar fascia must be
incised to gain proper exposure
3. Vessel loop or Babcock clamp placed proximal to
the stone to prevent frustrating stone migration
4. Longitudinal incision over the stone with a hooked
blade to expose the calculus
5. Nerve hook to tease out the stone