NEPHROLITHIASIS (nephrolithiasis; synonym nephrolithiasis) — the chronic disease which is characterized by disturbance of exchange processes in an organism and local changes in kidneys with education in their parenchyma, cups and a pelvis of the stones forming from salt and organic compounds of urine. Item. is the main and most frequent manifestation of an urolithiasis, or urolithiasis (see), consisting available urinary stones in kidneys, a bladder and an urethra.
«The stone disease» is known from an extreme antiquity what monuments to writing of Ancient Egypt, Persia, China, India, etc. testify to. Stones of a bladder and kidneys are found in mummies with prescription of burial of 3500 — 4000 years BC. The first description of operation of a lithotomy belongs to the Roman doctor A. Tsels (1 century AD). There would be data on P.'s treatment. in the period of the Middle Ages. At the end of 17 century data on a structure of urinary stones and crystals of uric salts are published. From the second half of 19 century, thanks to development of morphology, topographical anatomy, implementation laboratory and rentgenol. methods of a research, idea of P. received scientific justification. In Russia the first operation at P. N. V. Sklifosovsky in 1883 made. The significant contribution to the doctrine about P. S. P. Fedorov, R. M. Fronstein, M. A. Mir-Kasimov, G. S. Grebenshchikov, A. Randall, Carrhae (J. A. Carr), Boyce brought (W. N of Boyce), etc.
Item. meets in all districts of the world, but it is widespread unevenly. Rather low incidence is observed in nek-ry districts of the North, Africa, etc. Areas with frequent incidence (the local centers) are located in the countries of the Middle East, India, China, Australia, Latin America and certain regions of Europe. This disease is also widespread in the USSR unevenly. So, in districts with a frigid and temperate climate annual incidence makes 0,19 — 1,0 and 10 000 inhabitants above, in local districts of the republics of Central Asia and the Caucasus annual incidence fluctuates within 2,5 — 3,6 and more on 10 000 inhabitants. According to most of urologists, P. makes 25 — 35% of all diseases of kidneys of a surgical profile. The disease meets almost identical frequency at men and women. Stones are localized slightly more often in a right kidney, than in left, is more often in a pelvis, than in cups, or at the same time in a pelvis and cups. Frequency of an arrangement of stones in kidneys and uric ways is presented in the figure 1. However these data can change depending on age of patients, a klimatogeografichesky zone and other reasons. On chemical structure stones happen oxalic — to 40% of cases, phosphatic — in 27 — 30%, uratny — in 12 — 15%, tsistinovy and proteinaceous — to 1%, the mixed structure — in 20 — 30% of cases. The ratio of stones of various chemical structure at patients is also unequal; it depends on a klimatogeografichesky zone, conditions of the environment, content of salts in drinking water and foodstuff, character of food, age. At advanced age uratny and phosphatic stones, in young — oxalic come to light more often.
P. can result from influence single and multiple factors, have an exogenous and endogenous origin. The chemical structure and microstructure of urinary stones in many respects depend on the reasons of their education. So, at disturbance of purine exchange uratny stones can be formed, at disturbance of exchange oxalic to - you — oxalic; phosphatic stones appear generally at disturbance of phosphorus-calcium exchange and in the presence of the infection of uric ways causing alkali reaction of urine.
Disturbance of phosphorus-calcium balance in an organism is possible owing to several reasons. The main regulating role in exchange of calcium and phosphorus is played by epithelial bodies. At excess receipt the hypercalcemia (St. 11,5 mg / 100 ml), a hypophosphatemia develops in blood of parathormone from epithelial bodies (owing to adenoma, a hyperplasia, etc.) at patients (it is lower than 2,5 mg / 100 of ml), a giperkaltsiyuriya (St. 250 mg in daily amount of urine). At these patients also other manifestations of disturbance of fosfornokaltsiyevy exchange are possible; decalcification of bones, dispeptic disturbances, muscle pains, etc. Primary hyperparathyreosis (see) as P.'s reason. it is revealed at 2,8 — 10% of patients. The hypercalcemia can be also idiopathic, arises at an injury of bones, a disease of Recklinghausen, Pedzhet's disease, Beck's sarcoidosis, a hypervitaminosis of D, long reception of alkalis, salts of calcium, hard drinking water, etc. Giperkaltsiyuriya of any origin promotes to a nephrocalcinosis (see) and to a lithogenesis (lithogenesis).
Disturbance of metabolism oxalic acid (see) would play a part in P.'s emergence. with formation of oxalic stones or salts. Daily allocation oxalic is normal to - you with urine make 30 i of 15 mg, at patol, states it can be 200 mg and more. Oksalaturiya (see. Oksaluriya ) develops also owing to the increased adsorption oxalic to - you in went. - kish. a path, especially at excess receipt it with food. According to Hoffman (A. F. Hofman), Daulinga (R. N of Dowling), etc., oxalic to - some microorganisms and fungi of intestines can synthesize that. Long reception ascorbic, lemon to - you at nek-ry patients promotes development of an oksalaturiya. An endogenous source of oxalates at the person is glyoxylic to - that, formed generally of glycine. Excess of glycine in an organism can be at disturbance of carbohydrate metabolism and others patol, states. Deficit in an organism of rat anti-acrodynia factors and And increases excretion oxalic to - you kidneys, edges enters connection with calcium (at pH 5,5 — 5,7), crystallizes and drops out in a deposit in the form of calcium oxalate.
In P.'s development. with formation of uratny stones and uric salts etiol, a role is played by disturbance purine exchange (see). Uric to - that comes to blood from two sources: exogenous — from protein of food and endogenous — from the purine bases which are formed during the splitting of DNA and RNA in the conditions of a proteinaceous catabolism and treatment of cyto-proliferative processes (a disease of blood, some general diseases, etc.). Sometimes the hyperuricemia (increase in contents uric to - you in blood) has family and hereditary character. Besides, the hyperuricemia can arise owing to disturbance of a reabsorption uric acid (see) at nefropatiya, toxic impacts on kidneys, etc. A lithemia of St. 4,5 mg / 100 ml and an urikuriya of St. 400 mg in daily amount of urine at patol. changes in kidneys can lead to formation of uratny stones or uraturia (see).
Inf. defeats of uric ways are etiol, P.'s factor. Hron, pyelonephritis (see), according to most of clinical physicians, often would meet at P. At many patients it is primary, i.e. would precede P.'s development., at a part of patients — joins the existing P. At pyelonephritis microcirculation, the Lymph drainage from a kidney and urodynamic are broken. The majority of the microorganisms causing pyelonephritis (colibacillus, proteas, a pyocyanic stick, staphylococcus, enterokokk, etc.), decomposes urea of urine, and the ammonia which is formed at the same time alkalizes I wet (see). At the expense of products of an inflammation (an urothelium, erythrocytes, leukocytes, slime, etc.) hydrophobic colloids collect, viscosity of urine increases. In alkaline condition phosphates easily drop out in a deposit, there is a possibility of development fosfaturiya (see) or formations of phosphatic urinary stones.
Defined etiol, communication would exist between P. and nek-ry diseases. So, at anomalies of development of kidneys and uric ways the lithogenesis occurs generally in the presence urostasis (see), or urinary stasis, and accession of an infection. Tumors of a small pelvis, obstruction of uric ways also promote an urinary stasis and a lithogenesis. At a peptic ulcer of a stomach, hron, coloenterites the increased adsorption of calcium, oxalic to - you and other connections with the subsequent excretion their kidneys and a lithogenesis is possible. Malaria contributes to formation of oxalic and uratny urinary stones owing to the increased biosynthesis uric and oxalic to - t.
In nek-ry local districts seasonality of development of P. is noted.: at people in summertime salt content in urine sharply increases, morphological and functional changes in kidneys which can serve as a releaser of a lithogenesis are at the same time observed.
Urinary stones can be formed (as secondary) in uric ways on foreign bodys.
the Pathogeny at P. difficult and in many respects depends on features etiol, factors which can change in the course of a disease. There would be a number of theories of a pathogeny of P. According to the colloid and crystallizational theory for origin of a stone a certain situation is necessary, at a cut high salt content and availability of hydrophobic colloids in urine, and also the size pH of urine and an urinary stasis corresponding to a point of crystallization of the available salts are combined. In the absence of an urinary stasis and patol, changes in a colloid system of urine process comes to an end with formation of free crystals.
Can be the beginning of formation of primary center of a stone both crystallization of salts, and a conglomeration (coprecipitation) of organic matters; it depends hl. obr. from in what of two environments of urine (colloid or salt) changes are originally more expressed. Growth of stones happens rhythmically, to alternation of processes of crystallization of salts and sedimentation of organic matter (see. Urinary stones ). Origin of stones can also begin at the level of tubules where find microlites in the form of spheres and other forms. Colloid kri-stallizatsionnaya the theory is considered the most evidence-based and proved.
According to other theory, authors a cut are Randell and Carrhae, origin of urinary stones can happen on renal nipples. Carrhae found in tissue of a kidney of a microparticle (concretion), calciferous and glikolizoaminoglikana. In his opinion, there is a continuous movement of the formed concretions in limf, system of a kidney. At disturbance of a lymph drainage owing to pyelonephritis, a pedunkulit, and also at an overload of a kidney conditions for development of a nephrocalcinosis and a lithogenesis arise salts of calcium, etc. Concretions migrate towards renal nipples, forming on them plaques which were described by Randell. These plaques squeeze capillaries of nipples and can cause a necrotic papillitis (see. Renal nipples necrosis ). On nekrotizirovanny renal nipples salts crystallize and stones arise (apprx. 8 — 10% of stones).
Other earlier created theories of a lithogenesis (alimentary, infectious) lost the value and only supplement the above described theories.
Morfol. changes at P. differ in a variety and depend on localization of stones, their size, prescription and a look patol, process, existence of an infection, etc.
In initial phases of a disease in system of nephron so-called minimum changes of balls are found (see. Glomerulonephritis, pathological anatomy ), followed by a hyperpermeability of the glomerular filter. Microscopically in a gleam of capsules of balls and proximal tubules the proteinaceous and carbohydrate exudate which reabsorbirutsya by proximal tubules in the form of CHIC-positive granules is defined. Electronic microscopically find a large number of the phagosomas and lysosomes including rezorbirovanny belkovouglevodny complexes in nephrocytes. These complexes as in a gleam of tubules, and intracellularly are an organic matrix for the subsequent adjournment of lime. Salts of calcium in a significant amount are laid also in mitochondrions of nephrocytes.
Lysosomes (see) with inclusions of lime and nekrotizirovanny nephrocytes are allocated in a gleam of tubules and move to distal departments of nephron as microlites. Calciphied lysosomes can get through a basal membrane of a cell into intercellular substance and be a basis interkanat an ikulyarny lithogenesis. The described changes develop against the background of falloff in an epithelium of nephron of activity of the oxidoreductases, glycolytic enzymes and enzymes catalyzing reactions of a pentozny way.
Dystrophic and histochemical changes concern generally proximal tubules and gradually decrease towards distal departments of nephron. Parallel to changes of a tubuloepitelialny component of nephron inflammatory changes in intercellular substance in the form of alterativno-exudative and productive processes accrue; the limfoplazmotsitarny infiltrates which are localized preferential in the field of deeper damages of nephron to zones come to light calcification (see).
Accession of a purulent infection is shown by formation of limited abscesses and diffusion leukocytic infiltration of a stroma.
Quite often at P. find the centers of dystrophic calcification in nipples of pyramids (Randell's plaque). Sequestration of these plaques together with an organic matrix of a nipple can be a kernel of a free intrapelvic stone.
Further changes of kidneys are caused by the progressing pyelonephritis and disturbance of outflow of urine owing to increase in the sizes of a stone. The occlusive stone of a pelvis can cause expansion of cups (hydrocalycosis) or a piyel-ectasia, and further hydronephrosis (see). At the same time the parenchyma of a kidney is exposed to a gradual atrophy and a sclerosis with formation finally of the thin-walled bag filled with liquid. At a hydrocalycosis gradual expansion of renal tubules respectively in a zone of obturation is observed. In the subsequent such tubules gradually lose an epithelial vystilka, and on their place retentsionny cysts are formed. Obturation a stone of an ureter causes expansion of its proximal department, and also a pelvis and cups (gidroureteronefroz). In a zone of an arrangement of a stone there can be decubituses and an inflammation of a wall of an ureter (see. Ureter , ureteritis ), and further its stricture, the perforation is rare. The calculous aseptic hydronephrosis meets extremely seldom as disturbance of outflow of urine most often is complicated by the ascending or hematogenous infection; at the same time there is a calculous pyonephrosis, a pyoureteronephrosis. At relative safety of a parenchyma of a kidney apostematous nephrite and an anthrax of a kidney develop. The inflammation quite often passes to pararenal cellulose with education acute purulent or hron, paranephritis (see). At hron, a paranephritis the kidney is immured in the thick capsule consisting of granulyatsionny fabric and the sclerosed fatty tissue. Substitution of an atrophied kidney is much less often observed by a fatty tissue (fatty substitution of a kidney).
At bilateral damage of kidneys the renal failure which is a proximate cause of death gradually develops.
P.'s Manifestations. extents of disturbance of urodynamic, quantity, a form and localization of stones, duration of a disease, existence of complications (pyelonephritis, a renal failure, arterial hypertension, etc.) - Subjective signs of P. are various and depend on function of kidneys. pains — stupid, aching, constant, periodically acute, caused by renal colic are, edges can be single or repeatedly repeat without any patterns. Colic arises at localization of stones in a lokhanochnomochetochnikovy segment or in fiziol more often. narrowings of an ureter (ureteric colic). The bad painful attack is caused by sharp disturbance of outflow of urine from a kidney, increase in intrapelvic pressure, stretching of a fibrous renal capsule, disturbance krovo-and lymphokineses in it. Pains are localized in lumbar area and can extend to side and lower parts of a stomach, being followed by reflex paresis of intestines. At renal colic patients are uneasy, often change situation. Nausea and vomiting accompany renal colic approximately at 1/3 patients, sometimes there are oznoba and fervescence at the expense of a resorption of urine. These manifestations are more expressed at the accompanying acute pyelonephritis (see), at Krom owing to refluxes in venous and limf, systems from a kidney get together with urine products of an inflammation. At acute calculous pyelonephritis bacteriemic shock can develop. At stones only (or only functioning) kidneys at renal colic there can be obturatsionny anury (see), edges, according to M. D. Javad Back, etc., would occur at 1 — 2,7% of sick P.
Asymptomatic current of P., especially at korallovidny stones, it is observed at 7 — 10% of patients. The first symptoms of a disease can be found in them only on the basis of analysis findings of urine (a leukocyturia, a microhematuria, alkali reaction of urine, etc.).
Wedge, picture at localization of stones in an ureter almost same, as well as at stones of a kidney. The main differences of ureteric colic — localization of pains on the course of an ureter, irradiation of pains to the inguinal area, generative organs, an inner surface of a hip, quite often a dysuria.
Wedge, picture P. at persons of advanced and senile age has some features: it is less expressed; renal colic meets by 3 times less than at patients at young age; almost in 30% of cases the bezbolevy current owing to decrease in a tone of uric ways is observed; calculous pyelonephritis, a renal failure meet more often. The symptomatology of acute calculous pyelonephritis can also be atypical and erased.
Main complications of P. — pyelonephritis, a renal failure, a hydronephrosis, arterial hypertension (see. arterial hypertension ). Acute calculous pyelonephritis at the wrong or overdue treatment quickly passes from serous in purulent — apostematous nephrite (see), an anthrax of a kidney (see. Kidneys, pathology ). At the same time danger of development of bacteriemic shock and urosepsis is real (see. Sepsis ).
Renal failure (see) can be acute at the sudden block of uric ways and urine, chronic owing to long disturbance of outflow, and pyelonephritis.
the Diagnosis is made on the basis of data of the anamnesis, by a wedge, pictures, laboratory and rentgenol, researches. In the anamnesis the prescription of display of a disease, frequency of an otkhozhdeniye of stones, uric salts (sand), renal colic, etc. is established. Subjective and objective signs of display of a disease, pyelonephritis, renal failure come to light. At inspection pay attention on etiol, P.'s factors., disturbance of phosphorus-calcium and purine exchange, manifestation of an oksalaturiya, existence of an infection of uric ways, urostasis.
Hamaturia (see) at P. comes to light at 80 — 90% of patients, and it can be both micro, and macroscopic. The hamaturia arises after an exercise stress more often. At patients with uratny stones find the increased contents uric to - you in blood serum and daily amount of urine. At multiple and korallovidny stones, at repeated emergence of stones investigate phosphorus-calcium exchange, at suspicion on a giperpa-ratireoidizm apply special tests. All patient investigate microflora of urine, define degree of a bacteriuria, etc. Changes in urine of inflammatory character would come to light at 60 — 85% of sick P.
Absence of an infection in urine at P. happens on average at 25% of patients, generally to oxalic and uratny stones of kidneys and ureters. Reasonablly in dynamics to define pH of urine.
Diagnosis of typical renal colic is not difficult. Acute sudden pains in lumbar area with a certain irradiation, uneasy behavior of the patient, a microhematuria, in a survey picture and excretory Urogramum (see. Urography ) the increased kidney (a symptom of a nefrografiya — lack of the image of pyelocaliceal system on the party of defeat owing to blockade by its stone) — the most characteristic signs. In doubtful cases renal colic needs to be differentiated with acute diseases of abdominal organs and acute ginekol, diseases (see. Acute abdomen , Psevdoabdominaljny syndrome ). Help with differential diagnosis a laparoscopy (see. Peritoneoskopiya ), a puncture of a back vault of the vagina at women, local thermometry, a termografiya.
Rentgenol, a method would be main in P.'s diagnosis. It allows to reveal not only existence of stones, but also to establish their form, size, localization, structure, and also to gain an impression about changes in an anatomo-functional condition of kidneys and uric ways. The research is begun with a survey X-ray analysis of an abdominal cavity, beginning from Th11 to a pubic joint. Detection on the survey roentgenogram of a shadow, suspicious on a concrement, does not demand differential diagnosis only in case of the korallovidny stone which is a mold of pyelocaliceal system (fig. 2). Stones of renal cups represent their molds or have the irregular, rounded form; stones of a renal pelvis often roundish or triangular; stones of an ureter — cylindrical, spindle-shaped or irregular shape. At anomalies of uric ways the concrement can be out of usual localization of kidneys and other bodies of urinogenital system. Detection of a stone in a picture depends on its sizes, chemical structure and localization. Oxalates, then stones of the mixed structure and phosphates give the most intensive image. Oxalates have aculeiform, scalloped contours and remind mulberry berry. Korallovidny stones are most often compact, but can be layered, as well as other concrements of the mixed structure, sometimes they reach the huge sizes. Lamination of stones on roentgenograms is caused by permeability variations for x-ray emission of the salts making them. Apprx. 10% of stones with low atomic weight (urates, proteinaceous, tsistinovy and ksantinovy stones) are not visible or give a vague shadow. It is especially difficult to reveal the stones which are projected on a bone skeleton (edges, cross shoots of vertebrae, sacroiliac joints). Make aim pictures in slanting and atypical projections for their detection, tomo-or a zonografiya. Tomography (see), applied independently or in combination with contrast researches, it is shown by insufficient training of the patient to rentgenol, to researches, the renal colic which is followed by paresis of intestines or at the small sizes of stones. As at P. quite often concrements spontaneously depart from pyelocaliceal system, they can be projected on the course of an ureter paravertebral-but, tend to be late over one of its anatomic narrowings. The most important data on accessory of the revealed shadow to uric ways, about localization of a stone, the renal failures caused by it, urodynamic, an anatomic condition of uric ways (the hydrocalycosis, piyet an ectasia, gidroureteronefroz — expansion of cups, a pelvis, an ureter and a kidney) come to light at excretory Urografinum (fig. 3, b) with a preliminary survey X-ray analysis (fig. 3, a). She allows to establish a type of a pelvis (opened or closed, intra renal or extrarenal), a condition of a lokhanochno-ureteric segkhment (see. Piyelografiya ). Usually X-ray positive concrement is defined in uric ways, but sometimes its image is blocked, as if sinks against the background of the contrasted urine, especially at a small stone or small intensity of its image. At X-ray negative stones defect of filling of uric ways (including and a pelvis) with accurate contours (fig. 4) is visible. Unlike a tumor of a pelvis in slanting projections around a stone the rim of a contrast agent remains. Usually at the stones of a pelvis having a diameter of 3 cm and more are observed piyet an ectasia and a hydrocalycosis. Made in the course of excretory Urografinum a television piyeloureteroskopiya in combination with cinematography or video tape recording of the image allow to estimate disturbances of a tone and motor function of upper uric ways at stones, to distinguish spastic, funkts, processes from organic. If the stone which went down in an ureter partially closes it, then the megaloureter and a pelvis (pyeloureterectasis) higher than the level of an arrangement of a concrement are noted. On the excretory Urogramums made during renal colic the increased kidney with the strengthened nefrografichesky effect without contrasting cup lokhanoch comes to light - ache system and an ureter — a so-called big white kidney. Such rentgenol. the picture specifies that function of a kidney is kept. At a long total block a stone (more than 3 — 4 weeks) function of a kidney because of an atrophy decreases and can be lost completely. On the excretory Urogramums made after renal colic penetration of the contrasted urine out of limits of uric ways, and also a lokhanochno-renal reflux sometimes is observed. The retrograde piyelou-reterografiya with a liquid contrast agent or oxygen is made only at considerable depression of function of kidneys, at doubt in the diagnosis, especially when at excretory Urografinum does not come to light a X-ray negative stone. The X-ray analysis of an ureter after introduction of a catheter to it is made in direct and slanting projections. If at the same time the shadow, suspicious on a stone, in both pictures is near a catheter or P.'s diagnosis merges with its shadow, then. does not raise doubts. The shadow which is not relating to an ureter is defined on nek-rum distance from a catheter. On retrograde piyelogramma with a liquid contrast agent of small concentration X-ray negative stones come to light in the form of defect of filling. Especially demonstrative such stones become at a pnevmopiyelorentgenografiya or a pnevmopiyelotomografiya (fig. 5). By means of a retrograde ureterografiya it is possible to reveal a X-ray negative stone in an ureter, the upper bounds of defect at the same time have the concave form (fig. 6).
For the final decision of a question of expediency of operational elimination of occlusion and a possibility of recovery of function of a kidney after removal of a stone, clarification of vascular very tectonics if the nephrectomy is supposed, the multiple nephrotomy and removal of korallovidny stones, resort to renal angiography (see). Reduction of caliber of a renal artery by 50% and with a reduction of intraorganic branchings states on sharp, often irreversible dysfunction of body above. Because of a possibility of migration of a stone just before operation it is necessary to repeat a survey picture of uric system for specification of its localization. In the course of an operational removing calculus use a television piyeloureterosko-piya or a X-ray analysis of a naked kidney for the purpose of control of removal of all concrements or their splinters. At nek-ry patients after piyelo-or ureterolithotomies can arise strictures, deviations of an ureter with disturbances of urodynamic and dilatation of upper uric ways.
According to special indications, especially at X-ray negative stones at patients with intolerance of iodide drugs, apply a computer tomography (see. Tomography computer ), and also ultrasonic diagnosis (see).
In P.'s diagnosis. for definition of function of kidneys, blood supply and urodynamic use tracer techniques of a research (tsvetn. fig. 1 — 6): a renografiya (see. Renografiya radio isotope ) and dynamic stsintigrafiya (see).
Treatment conservative and operational. Conservative treatment — dietary food, medicamentous, a dignity. - hens. treatment, LFK, physiotherapeutic procedures. Dietary food (see. clinical nutrition ) would appoint taking into account P.'s etiology., disturbances of phosphorus-calcium exchange, exchange oxalic to - you, purine exchange, chemical structure of urinary stones or uric sand, pH of urine, a functional condition of kidneys, etc.
At an oksalaturiya and oxalic stones it is necessary to limit consumption of the products containing a lot of oxalic and lemon to - that (salad, spinach, a sorrel, pepper, a rhubarb, bean, a gooseberry, currant, a wild strawberry, a citrus, etc.). At disturbances of carbohydrate metabolism limit carbohydrates (sugar, grapes, etc.). Meat, fish, vegetable oils, farinaceous, groat dishes, vegetables (beet, cucumbers, cabbage, melons, water-melons), fruit are recommended to patients preferential in a boiled look (apples, pears, cherry, etc.). As ions of magnesium block crystallization of calcium oxalates, appoint is long drugs of magnesium (magnesium oxide, magnesium thiosulphate, magnesium carbonate on 0,5 g 2 — 3 times a day after food). Apply also methylene blue capsular 0,1 g 2 — 3 times a day. Periodically appoint inside rat anti-acrodynia factor (a pyridoxine on 0,01 g 2 — 3 times a day). For reduction of concentration of oxalates in urine and increases in pH of urine it is recommended to increase reception of liquid to 2 — 2,5 l a day.
Conservative treatment patients with uratny stones and an uraturia it is directed to restriction of the products containing purines (cocoa, coffee, chocolate, a liver, meat). The proteinaceous structure of food shall be no more than 1 g on 1 kg of weight of the patient. Beef-infusion broths are contraindicated; meat, fish are recommended to use preferential in a boiled look. In a diet milk and vegetable products prevail. At a hyperuricemia and an urikuriya use the drugs reducing synthesis uric to - you (Allopyrinolum on 0,1 g 2 — 3 times a day), under control of level uric to - you blood sera. At an uraturia, an otkhozhdeniya at military stones at the same time periodically appoint drugs of citrates. For decrease in concentration of uric salts increase reception of liquid to 2 — 2,5 l.
The patient with uratny (X-ray negative) stones at satisfactory function of kidneys and urodynamic, absence of acute pyelonephritis appoint so-called solvents — drugs of citrates (Magurlitum, Soluranum, etc.). Their dosage is individual and is regulated in the course of treatment depending on pH of urine (it is necessary to support pH within 6,2 — 6,9). A course of treatment of 1,5 — 2,5 months with the subsequent control rentgenol, a research. In some cases treatment yields a positive take (fig. 7). In the absence of effect repeated courses of treatment are inexpedient.
The principles of treatment at tsistinovy stones same, as well as at at military.
At phosphatic stones and a fosfaturiya limit in food calcium (dairy products, potatoes, eggs, etc.), exclude the products and pharmaceuticals alkalizing urine (lemons, alkalis, etc.). Recommend the products promoting oxidation of urine (meat, fish, fats, vegetable oils, butter, etc.). Drug antibacterial treatment is directed to suppression of the infection alkalizing urine; apply the means promoting oxidation of urine (glutaminic to - that, methionine on 0,5 g 3 times a day, ascorbic, boric, the benzoic to - you on 0,2 g 2 — 3 times a day, etc.). Reception of liquid to 1,5 l.
Patients with stones of the mixed and changing chemical composition of uric salts shall have a various food, with restriction of the products promoting formation of salts.
At the same time carry out by all patient the treatment directed to recovery of urodynamic, elimination of an urinary stasis, normalization krovo-and lymphokineses in kidneys.
Apply to exile of small stones of kidneys and ureters also Avisanum, Olimetinum, cystenal, etc., physiotherapeutic procedures, LFK and balneoterapiya. Water loading, or so-called water blow, appoint 1 — 2 time a week at satisfactory to urodynamic: patients accept spasmolytic drugs and 1,5 l of weak tea or warm water within 1 — 2 hour. Treatment by water loading contraindicated at renal colic, disturbance of urodynamic, cardiovascular diseases, an idiopathic hypertensia, etc. In the absence of effect catheterization of an ureter is made (see. Catheterization of uric ways ) usually in combination with a hromotsistoskopiya.
For removal of renal colic use spasmolytic drugs (a papaverine, Nospanum, Baralginum, atropine, etc.), anesthetics (Promedolum, etc.), at ureteric colic make novocainic blockade of a seed cord (at men) or a round ligament of a uterus (at women) according to Lauryn-Epshtey-well (see. Novocainic blockade ). During an attack of renal colic for the purpose of elimination of a spasm of an ureter, the termination of pain and apply heat in the form of the general bathtubs at water temperature to an otkhozhdeniye of stones 38 — 39 ° lasting 10 — 20 min., radiation of lumbar area a lamp sollyuks within 20 — 30 min., paraffin or ozokeritovy applications at t ° 48 — 52 ° on lumbar area, hot-water bottles, inductothermy (see) or influence within 15 — 20 min. decimeter waves at such intensity of energy when the patient has a feeling of moderate heat (see. Microwave therapy ). During the mezhpristupny period (most effectively at once after colic) if the stone has conditions for an otkhozhdeniye of concrements (lack of acute ledges, a low arrangement, the size to 10 mm, lack of the expressed dilatation of an ureter), for the purpose of strengthening of reduction of an ureter, stimulations of an otkhozhdeniye of a stone on uric ways apply influence by the harmonic modulated currents (see. Impulse currents ) in combination with water loading and heat. The patient drinks not less than 1/2 l of liquid, in 30 — 40 min. within 20 min. carry out an inductothermy) or influence by decimeter waves on area of kidneys and an ureter. At the same time the patient shall feel moderate heat. Also other option is possible: the patient takes a heat bath, then within 10 — 15 min. influence the harmonic modulated currents. At localization of concrements in an upper and average third of an ureter the electrode of 4 in size of the X piece would be placed on area of a projection of a pelvis, and the second — 8 in size — 12 X 12 — 15 cm — over a pubic symphysis from the relevant party. At localization of a stone in lower parts of an ureter at first within 5 — 8 min. influence the harmonic modulated currents, having arranged electrodes as it is stated above, and then during the same time — having placed a small electrode over a pubic symphysis, and big — on lumbar area.
Balneological treatment (see. Balneoterapiya ) carry out in the resorts of Truskavets, Zheleznovodsk, Berezovsky, Shklo, Dzhermuk, Yessentuki, etc. The main indications to the direction of patients on a dignity. - hens. treatment: the small stones capable to depart independently and not breaking urodynamic, uric diathesis (an uraturia, an oksalaturiya, to phosphate-riya, the Cystinuria); besides, dignity. - hens. patients after an operational removing calculus or an ureterolitoekstraktion are subject to treatment (in 1 — 1,5 month in the absence of acute pyelonephritis). Use the mineral waters rendering diuretic effect, possessing spasmolytic and antiinflammatory action, influencing pH of urine and reducing its viscosity. At uratny and oxalic stones or uric salts and acid reaction of urine waters Yessentuki No. 4, Slavyanovskaya, Smirnovsky, Berezovsky are shown, to Naftusya, etc., the acidities of urine promoting reduction. The patient with phosphatic stones and a fosfaturiya at alkali reaction of urine waters Dolomite narzan, Arzni, Marcial waters, Naftusya, etc. are reasonable.
At P. widely apply LFK promoting an otkhozhdeniye of a stone, improvement of urination, stimulation of a metabolism. Physical exercises, causing fluctuations of intra belly pressure, change a tone of unstriated muscles of an ureter, stimulate its peristaltics and promote an otkhozhdeniye of a stone. The indication to purpose of LFK is existence in any department of an ureter of a stone, completely occlusive its gleam, and the sizes of a stone shall not exceed 1 cm since stones of the bigger size cannot independently depart.
A contraindication to LFK — the obturation of an ureter which is followed by fervescence and pains, a renal failure, and also the stones located in a cup or a pelvis. The LFK main form — gymnastics. Before uprazhneniyakhm appoint diuretic and antispasmodics, reception of a large amount of liquid. Use special exercises for muscles of a prelum abdominale, inclinations, a progibaniye and turns of a trunk, the movement with jump of position of a body, run, jumps, dismounts from shells; frequent change of initial positions (standing, sitting, lying on spin, on one side, on a stomach, an emphasis being kneeling, etc.). These exercises alternate to relaxation of muscles and breathing exercises. Duration of occupation of 30 — 45 min. Krom to lay down. gymnastics, it is recommended to carry out independently for day special exercises, in morning a gigabyte. gymnastics to include 2 — 3 special exercises, walking, dismounts from steps of a ladder, etc.
In the absence of effect of drug treatment and physical therapy and an acute disorder of outflow of urine it can be applied endovesical ureterolitoekstraktion, for a cut several extractors — Johnson are offered, to Dormia, Pasch-kovsky, Tseyssa (fig. 8), etc. Their components are the catheter, the conductor and the gripping holder (a loop, a basket), in nek-ry of them there are devices for management of an extractor and fixings of a stone in a basket.
As the main indications to an ureterolitoekstraktion serve stones of a lower part of an ureter of the small sizes (to 0,8 cm), lack of signs of a periureteritis, preservation of a satisfactory tone of an ureter.
Contraindications to bringing down of stones of an ureter — acute pyelonephritis, a pyonephrosis, a hydronephrosis, an anury, an urosepsis, a stricture, inflammatory diseases of an urethra, etc. At men the ureterolitoekstraktion should be applied extremely carefully because of a possibility of development of acute prostatitis, an urethremorrhagia and other complications.
Ureterolitoekstraktion is made in a hospital. The patient shall be inspected completely in connection with a possibility of an immediate surgery. Before extraction of a stone to the patient appoint spasmolytic and anesthetics (Platyphyllinum, atropine, Promedolum, etc.), make a X-ray analysis of uric ways. After use of various methods of anesthesia, including an anesthesia, an extractor enter into an ureter via the cystoscope so that the loop or its basket was carried out in closed form above a stone. Then open a basket of an extractor and reduce it. At the same time at the same time carry out easy rotary motions, trying to take a stone and to take it. When the stone cannot be brought out of an ureter, the extractor is left in a condition of a tension, to-rogo reached by means of suspension of a load to 200 and (via the block) for the term of 1 — 4 days to an otkhozhdeniye of a stone. At the same time use antibacterial and spasmolytic drugs. After extraction of a stone are recommended catheterization of an ureter within 2 — 3 days and antiinflammatory treatment.
The main complications of an ureterolitoekstraktion can be technical, traumatic and inflammatory character (a separation, «change» of an extractor, infringement of a stone, an exacerbation of pyelonephritis, perforation of a wall of an ureter, etc.). At impossibility of extraction of a stone apply an ureterolithotomy.
Operational treatment is the main method of a removing calculus from kidneys and ureters. Expediency of an early removing calculus, the sizes is proved to-rykh do not allow to hope for their independent otkhozhdeniye, especially at stones of the only kidney. The absolute indication to operational treatment of P. occlusive stones, a calculous anury, frequent constant pains, the expressed hamaturia, frequent attacks of renal colic, a pyonephrosis and a purulent paranephritis are. Indications to planned operations are strictly individual at patients with associated diseases and at senile age. Thanks to development of anesthesiology, nephrology, a possibility of use hemodialysis (see), to improvement of the technology of operations (a hypothermia of a kidney, temporary occlusion of a renal artery, extracorporal surgery, etc.) indications to operational treatment of patients with korallovidny stones extend.
As a contraindication to operational treatment serve stones of cups, parenchyma of a kidney without essential a wedge, manifestations.
Preoperative preparation depends on a condition of the patient, P.'s current., existence of complications (pyelonephritis, renal failure, etc.) and associated diseases.
At patients with hron, pyelonephritis in stages of an aggravation, especially at alkali reaction of urine, preoperative preparation includes antibacterial therapy.
At hron, a renal failure apply antiazothat-chesky and disintoxication therapy (intravenously solutions of glucose, electrolytes, plasma substitutes, anabolic hormones, cardiovascular means, vitamins, etc.). In some cases, especially at korallovidny bilateral stones and hron, a renal failure, use of a hemodialysis is possible.
At acute obturatsionny purulent pyelonephritis urgently make catheterization of an ureter, and at impossibility of its performance the immediate surgery is shown. As at these patients bacteriemic shock can develop, to them in the preoperative period hold a complex of antishock events, including introduction of corticosteroids, plasma substitutes, cardiovascular means, vitamins and DR-
of Patients with a diabetes mellitus before operation transfer to simple insulin (instead of drugs of insulin of the prolonged action and tableted antidiabetic means).
Anesthesia — an intubation anesthesia with muscle relaxants or peridural anesthesia; other types of anesthesia apply seldom.
Quick accesses — usually extra peritoneal lumbar according to Fedorov and Bergmanna (see. Lumbotomy ). In need of operation on an ureter it is possible to use Izrael's section or a pararectal Extra peritoneal section; at stones of its lower third — a section across Pirogov, etc. Single stones of ureters can be deleted through intermuscular accesses. There are also more rare quick accesses — a transperitoneal pyelolithotomy or an ureterolithotomy, etc.
At P. carry out the following types of operations: pyelolithotomy, piyelokalikolitotomiya, nephrolithotomia, kalikotomiya, nephrectomy, nephrostomy (see) and nephrectomy (see). Apply different types of a pyelolithotomy (fig. 9). The back longitudinal or cross pyelolithotomy is most widely used, at a small pelvis this section is carried out subkortikalno. The lower pyelolithotomy is recommended at an intra renal pelvis, the verkhnepoperechny pyelolithotomy is applied seldom. The front pyelolithotomy is shown preferential at anomalies of a form and position of kidneys. After removal of a stone most of urologists considers it expedient to take in tightly a section of a pelvis a catgut.
Along with a piyelotomiya at multiple stones of cups and korallovidny stones carry out in addition a nephrotomy. The stone is groped a needle and on it make a nephrotomy, on a section of a kidney put P-shaped catgut stitches. Operation is finished more often with a nephrostomy.
The nephrectomy is applied by hl. obr. at the gidrokaliksa filled with the fixed single or multiple stones, the narrowed necks of cups with the phenomena of a segmented nephrosclerosis. For this purpose use a plane and wedge-shaped nephrectomy. Operation is quite often finished with drainage of a kidney.
A nephrostomy at P. for temporary drainage of a kidney it is shown at the operations which are followed by renal fornikalny bleeding in the absence of confidence of removal of all stones (multiple, korallovidny) from a kidney, a purulent inflammation, disturbance of outflow of urine from a kidney, etc. At acute calculous apostematous nephrite, an anthrax of a kidney decapsulations it, the section of an anthrax and broad drainage of pararenal cellulose is in addition carried out.
Terms of removal of a nefrostomichesky tube depend on postoperative disease, recovery of a normal passage of urine, an otkhozhdeniye or removal of small concrements, salts and products of an inflammation. According to A. Ya. Pytelya, I. P. Pogorelko, average terms of preservation of a nefrostoma make 1 — 2 month. However at heavy destructive changes in a kidney and an ureter, lack of an opportunity to execute repeated operations of a nefrostom can remain also on more long term.
A nephrectomy, despite a tendency to carry out organ-preserving operations at P., it is applied quite often (10 — 15% and even more among all operations at sick P.). As the main indications to it serve the calculous pyonephrosis, a nonfunctioning kidney in the presence of a nephrosclerosis, an anthrax of a kidney with extensive destruction of its parenchyma, profuse bleedings, etc. In case of development of a heavy sclerosing paranephritis it is reasonable to apply sub-kapsulyarnuyu nephrectomies).
The postoperative period at P. has a feedforward with an etiology, a pathogeny of a disease and the nature of surgery. Antibacterial treatment is carried out depending on results bacterial, researches, sensitivity of microbes to antibiotics and himiopreparata. Food, drug treatment carry out depending on disturbances of exchange processes in an organism, function of kidneys, chemical structure of urinary stones, pH of urine, etc.; at a renal failure apply antinitrogen-michesky treatment, disintoxication means and anabolites (5 — 20% solution of glucose, retabolil, Haemodesum, vitamins of group B and C), at the phenomena of acidosis — alkali (4% solution of hydrosodium carbonate, etc.).
After operation early activation of patients and LFK is shown that improves urodynamic, eliminates paresis of intestines, prevents development of pneumonia, etc.
The pelvis of a kidney through nefrosty is periodically washed out antiseptic solutions. After removal of multiple phosphatic and korallovidny stones some urologists recommend long irrigation of a pelvis antiseptic solutions (Furacilin 1: 5000), and with 10 — the 12th day in addition appoint the drugs promoting dissolution of phosphatic salts and reduction of viscosity of urine (trilon-B, chymotrypsin, etc.). Irrigation is carried out on a two-channel drainage or specially established thin catheter.
The forecast at timely conservative and operational treatment of P. rather favorable. It is worse at korallovidny, multiple and bilateral phosphatic stones. Would have an adverse effect on P.'s current. disturbance of urodynamic and urinary stasis, resistant alkali reaction of urine.
The postoperative lethality averages 1 — 2,5%. Its main reasons — an end-stage of a renal failure, uraemia, an urosepsis, tromboembolic and other episodes.
A recurrence of stones at P. can be true and false, the last more often are after removal of multiple and korallovidny stones. A true recurrence of stones is observed in 3 — 5% of cases at aseptic stones, in 10 — 12% — at infected, 20 — 46% — at korallovidny, multiple and bilateral stones.
Prevention depends on features of an etiology, P.'s pathogeny. also is individual. Preventive events are held taking into account disturbances of those exchange processes, at to-rykh there is a lithogenesis. At purpose of a diet and drug treatment it is necessary to consider pH of urine (to support within 6,2 — 6,9). At the increased concentration of uric salts, salt diathesis it is necessary to increase reception of liquid to 2 — 2,5 l. Patients shall stay on the dispensary registry, the main objectives to-rogo is observation, antirecurrent treatment, labor recommendations, selection of patients on a dignity. - hens. treatment and their timely hospitalization.
The nephrolithiasis at children
the Nephrolithiasis at children makes 15 — 48% of number of all diseases of urinogenital bodies, and in the local centers — 55 — 76%. At children more often than at adults, P. would be observed. with bilateral defeat, korallovidny and multiple stones.
In P.'s etiology. along with exchange disturbances in an organism an important role is played by anomalies and malformations of urinogenital system, a dysplasia, the disproportional development of various parts and bodies creating conditions for an urinary stasis. Among the acquired factors there is P.'s development. inflammatory diseases of uric ways matter. They promote development of processes of a lithogenesis or the phenomena of an urinary stasis. At children stones from salts oxalic to - you meet more often, is more rare phosphoric and mixed.
At advanced age disease at children usually does not differ from its current at adults, but a leukocyturia, a hamaturia are observed more often and can be the only display of a disease, at the same time the microhematuria prevails. The painful symptom meets less often, it can be shown in the form of renal colic or have character of dull aches. Pains are localized in a navel or extend on all stomach, often are followed by disorders of function went. - kish. path. At survey of the child it is possible to reveal scoliosis, muscle tension of an abdominal wall on the party of a stone.
Item. at children it is usually combined with pyelonephritis, the current to-rogo happens, as a rule, chronic. P.'s combination. and a hydronephrosis it is observed seldom.
The most frequent complication of P. the renal failure developing more than at V3 of children, hl is. obr. at bilateral defeat. Hron, a renal failure begins to form at early children's age, reaching a maximum of manifestations by 7 years. Much less often such complications as a pyonephrosis, a paranephritis, a calculous anury meet.
In P.'s diagnosis. at children the main place belongs rentgenol, to methods. At children, especially at early age, the excretory urography is the most available and informative, and at times and only method of a research. At sharply reduced or absent function of kidneys it is possible to use the ascending ureteropiyelografiya.
The differential diagnosis is carried out with Vilms's tumor (see. Vilmsa tumor ), in cases of acute obturation a concrement — with an acute appendicitis (see. Appendicitis ), acute impassability of intestines (see), peritonitis (see).
P.'s treatment. at children preferential operational. Conservative treatment is admissible at a top functional and morphological condition of kidneys, at a stone, small on a razkhmer, and a possibility of its independent otkhozhdeniye. Age anatomo-physiological and immunobiological features of an organism of children of the first years of life are characterized by extreme activity of fibroblastichesky reaction of tissue of kidneys to inflammatory process (pyelonephritis), in a short space of time leads edges to development of a nephrosclerosis. Therefore operational treatment shall be the earliest irrespective of age and degree patol, changes in kidneys. At the choice of a type of operation it is necessary to consider the general condition, localization, quantity and the sizes of concrements, their combination to malformations of uric ways, a functional condition of kidneys, activity of pyelonephritis, a stage hron, a renal failure. Along with removal of concrements, whenever possible, remove the causes of an urinary stasis, i.e. make also reconstructive operation. At bilateral process surgery is performed on the party better than the functioning kidney, at identical changes in the beginning — on the party with more expressed pain syndrome. The serious condition caused by acute obstruction of uric ways is the indication to two-stage treatment: according to the emergency indications make a nephrostomy), then in a planned order carry out recovery of passability of uric ways. Multiple and korallovidny stones delete by a nephrolithotomia, at the same time cut a pelvis in transverse direction far from a lokhanochno-ureteric segment. A nephrectomy) make only in cases of considerable destruction of a kidney. In before - and postoperative the periods the attention is paid to correction of exchange disturbances, treatment of pyelonephritis.
P.'s recurrence. at children arise in 11% of cases.
Bibliography: Blagodarov V. of N, Change of kidneys at an urolithiasis according to a submicroscopy, the Doctor, business, No. 8, page 52, 1976; Diseases of kidneys, under the editorship of G. Mazhdrakov and N. Popov, lane with bolg., page 709, Sofia, 1980; Weinberg 3. C. Stones of kidneys, M., 1971, bibliogr.; Javad Back M. D. Stones of ureters, M., 1961, bibliogr.; Murvanidze D. D. and Gudzhabidze D. B. A nephrolithiasis at children, M., 1973, bibliogr.; Novikov I. F. Stones of ureters, L., 1974, bibliogr.; Olefirenko V. T. Water-teplole-cheniye, M., 1978; Ormantayev K. S. and Chichasova O. Ya. An urolithiasis at children, Alma-Ata, 1975, bibliogr.; Fundamentals of nephrology, under the editorship of E. M. Tareeva, t. 2, page 672, 841, M., 1972; Palivoda N. I. Korallovidnye stones of kidneys, Minsk, 1973; Poe-gorelko I. P. Urolithiasis, Tashkent, 1960, bibliogr; P at - A. T. and Kurkin's lats. V. Nefrolitiaz and pyelonephritis at children, Dushanbe, 1977, bibliogr.; Pytel A. Ya. and Pytel Yu. A. Radiodiagnosis of urological diseases, M., 1966, bibliogr.; T and r N. I. experts. A local urolithiasis in an arid zone, Ashgabat, 1978; T and to t and nanosecond to and y O. JI. Renal form, primary hyper parathyroidism, L., 1972; it, Urolithiasis, L., 1980; C and r f and with P. G. and Danilov Yu. E. Philosophy of treatment of patients in the resorts of the USSR, M., 1975; Yasnogorodsky V. G. and Pevzner P. N. Use of the harmonic modulated currents and an inductothermy for exile of stones of ureters, in book: Urgent vopr. wedge, kurortol. and fizioter., under the editorship of Yu. E. Danilov, page 233, M., 1971; In about n d e r H. o. Diagnostic and therapeutic aids in urology, Springfield, 1974; Calcium, phosphate and magnesium metabolism, ed. by B. E. C. Nordin, Edinburgh a. o., 1976; To soy G. L. Nephrolithiasis, pathogenesis and treatment, Chicago — L., 1978; D e u t i-with k e P. Die Rontgenuntersuchung der Niere und des Harnleiters in der urologi-schen Diagnostik, Miinchen — Grafelfing, 1974; Handbuch der medizinischen Radio-logie, hrsg. v. O. Olsson, Bd 13, T. 1, B. u. a., 1973; Heptinstall R. H. Pathology of the kidney, v. 2, Boston, 1974; Klinische Urologie, hrsg. v. Page E. Aiken u. W. Staehler, Stuttgart, 1973; Kneise O. u. Schober K. L. Die Rontgenuntersuchung der Harnorgane, Lpz., 1963; Pollack H. M. Radiologic examination of the urinary tract, Hagerstown, 1971; P at rah L. N. Renal calculus, V. a. o., 1979; T e i with li ma n n W. Untersuchungen von Harn und Konkrementen, B., 1975; Treatment of urinary lithiasis, ed. by A. J. Butt, Springfield, 1960.
V. S. Ryabinsky, I. S. Kolpakov; V. P. Illarionov (to lay down. physical.), P. N. Pevzner, V. G. Yasnogradeky (fizioter.), V. M. Perelman (rents.), N. K. Permyakov (stalemate. An.), A. T. Pulatov (it is put. hir.), G. A. Zubovsky (stsintigramma — tsvetn, fig. 1 — 6).