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Urinary stones

 Urinary stones

Urinary stones


Urolithiasis indicates the presence of stones in the urinary tract, which is the third most common pathology of the urinary tract (just behind urinary infections and prostate diseases). Because they can cause significant symptoms and problems, an active approach to treatment is sometimes required.

Urinary stones

Creation and division of urinary stones

Specificity of calcium-free stones

Symptoms of urolithiasis

Detection of stones and diagnosis

Therapeutic approach to urolithiasis

Active non-invasive and invasive treatment

Creation and division of urinary stones

Calcium-containing stones account for 80-85% of all urinary stones.

The stones are usually primarily formed in the kidney. The presence of calculus in the kidney is called nephrolithiasis, and the presence of calculus in the urethra (ureter) is called ureterolithiasis. Urolithiasis is the third most common pathology of the urinary tract, so about 12 percent of the world's population will have urolithiasis in one lifetime. The ratio of men to women is 3: 1, but in recent decades this difference has been narrowing.

 

The stones can be divided into calcium and non-calcium. Calcium-containing stones account for 80-85% of all urinary stones, and they most commonly occur due to elevated levels of calcium, uric acid and oxalate in the urine, as well as decreased levels of citrate in the urine. On the other hand, calcium-free stones are struvite stones made of magnesium-ammonium-phosphate, then clock stones made of uric acid crystals, cystine stones made of cystine amino acids.

 

Specificity of calcium-free stones

Calcium-free stones are struvite stones, urate stones and cystine stones.

Struvite stones make up about 10 pst stones and occur more frequently in women. Struvic stones are a consequence of urinary infections, most commonly when bacteria of the genus Proteus, Pseudomonas and Klebsiella containing urease, a specific urea-degrading enzyme, are found to be the cause. In such cases, alkalization of the urine occurs and the formation of struvite crystals. Foreign bodies (eg urinary catheter) and / or neurogenic bladder are conditions that increase the likelihood of urinary infection and consequently the formation of struvite stones.

 

Uratic stones usually occur in men and make up less than 5 percent of urinary stones. Patients with gout, myeloproliferative diseases and those treated with cytotoxic drugs for malignancies have an increased incidence of urinary lithiasis. However, most patients with urate lithiasis do not have elevated levels of uric acid in their blood. Elevated uric acid levels are often the result of dehydration / reduced water intake and increased purine intake. Adequate hydration (maintaining a urine volume greater than two liters per day), reducing purine intake and / or administration of allopurinol reduce uric acid excretion in the urine. Alkalisation of urine (oral alteration of sodium bicarbonate, potassium bicarbonate, potassium citrate) can break down urate stones (depending on the size of the stone).

 

Cystine stones are a consequence of the disruption of cystine amino acid transport in the renal tubules. In such cases, excessive cystine excretion occurs in the urine and formation of cystine stones. Cystic lithiasis accounts for an average of 1-2 percent of urolithiasis cases.

 

Symptoms of urolithiasis

Most often, the first symptom of urolithiasis is a sudden, severe, spasmodic lumbar pain (in the lower back) with spread to the groin / bladder, and sometimes to the testicles in men. These symptoms can be accompanied by blood in the urine.

 

In addition to pain, nausea and vomiting often occur. The stones in the final third of the urethra, in front of the bladder, can cause more urgent urge to urinate. Occurrence of fever, chills and tremors indicates infection, probably more severe obstruction / obstruction of the urinary tract with stone; in such cases you should definitely contact your doctor.

 

Detection of stones and diagnosis

Ultrasound examination determines the presence of kidney stones and the degree of possible obstruction of the urinary tract.

Stones that do not cause symptoms are detected by accident - ultrasound, X-ray, or computed tomography (CT). On the other hand, symptomatic stones are detected on the basis of clinical presentation and radiological examinations. It is necessary to perform an ultrasound examination to determine the presence of kidney stones (namely, stones in the urethra cannot usually be seen by ultrasound) and the degree of possible obstruction of the urinary tract.

 

Basic laboratory tests should also be performed, such as complete blood counts, then biochemistry (urea, creatinine, potassium) to determine renal function, as well as biochemistry / urine sediment in addition to urine culture (a matter of uroinfection). An X-ray of the urotract was then done; CT or intravenous urography can also be done as needed because the types of stones that are not displayed on classical X-rays can be visualized.

Therapeutic approach to urolithiasis

Adequate fluid intake (2.5 to 3 liters per day) increases the formation of urine and helps to divert small stones.

Small stones that do not cause symptoms, infection or obstruction are usually not required to be actively treated. Most stones are less than 5 millimeters in size and are usually spontaneously wetted by patients. Adequate fluid intake (2.5 to 3 liters per day) increases the formation of urine and aids in descaling.

 

Often, analgesic therapy is needed as the calculus passes, and alpha receptor blockers (tamsulosin) can be introduced into the therapy to "relax" the urethra and facilitate the elimination of calculus. Treatment of stones that are not spontaneously eliminated depends on their location, size, composition, shape, and the condition of the patient.

 

Active non-invasive and invasive treatment

An extracorporeal shock wave, percutaneous nephrolithotomy, endoscopic approach, and open surgery can be used in the active treatment approach.

The stones within the kidney deposit and in the urethra, especially the upper part of the ureter, can be crushed by ESWL (Extracorporeal Shock Wawe Lithotripsy). The procedure itself is monitored by X-ray or, less commonly, ultrasound. Stones up to 2 centimeters in size can be treated with this method and an outpatient procedure is performed. The chunks of limescale then spontaneously get wet.

 

Larger kidney stones (greater than 2.5 centimeters) and those that fail to be eliminated by ESWL can be removed by percutaneous nephrolithotomy (PCNL). It is a minimally invasive method by which through a small incision in the skin in the lumbar region the optic instrument (nephroscope) enters the canal system of the kidney and the calculus is ground (mechanical, electro-hydraulic, laser or ultrasonic) and the calculus fragments are then removed through the same instrument. The procedure is performed under general anesthesia.

 

The stones in the lower part of the urethra can also be removed endoscopically, ie. using a ureteroscope - a thin optical instrument that is introduced through the urethra and the bladder into the urethra. This will show the stone to be ground (mechanical, electro-hydraulic, laser or ultrasonic), and the resulting fragments then removed. The procedure is performed under general anesthesia.

 

Classic "open" surgery for kidney and ureter calculi (nephrolithotomy, ureterolithotomy) used to be the only method of treating calculus. Today, they are rarely used, only in 1-2 percent of cases, specifically in patients where none of the above methods can be done.

 



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